Proposed Abortion Bill raises issues

The publication of the Heads of the Protection of Life During Pregnancy Bill has, not unexpectedly, led to substantial political and societal debate. But what professional issues will arise for doctors who will be caring for patients under the new legislation?

The group of three doctors who will make an assessment of suicide ideation will comprise an obstetrician and two psychiatrists. They must "jointly certify in good faith" that (a) there is a "real and substantial risk" of the loss of the pregnant woman's life by way of suicide and (b) "in their reasonable opinion" this risk can be averted only by termination.

Notoriously inexact
Assessment of suicide risk is notoriously inexact, whether during pregnancy or not. Unlike many other medical conditions, there is no objective test available, not even one with a marginal rate of accuracy.

So when someone visits their GP with suicidal thoughts, the threshold for referral for specialist care is low. Equally for the psychiatrist seeing the same patient, an admission for further assessment would be the most common clinical decision.

In practice, therefore, assessing the threat to a suicidal pregnant woman’s life will take time. How appropriate will it be for a consultant obstetrician to formally assess suicidality?

It is fair to say the majority do not see women with suicidal intent with any regularity. Without specific training and practice in this area, can they ethically offer a considered opinion in such a case?

It would have been medically more appropriate to have included the patient’s GP in the three-doctor panel.

In practice, GPs assess people with suicidal thoughts more frequently than obstetricians; they tend to have had longer-standing relationships with the women that predate pregnancy, which can be invaluable in making what is already a challenging decision.

Another reason to give family doctors a more central role in the process is that a young suicidal girl in early pregnancy is far more likely to go first to a GP. All low-risk obstetric medical care in the Republic is provided in primary care until 18 -20 weeks’ gestation.

The rather harsh 14-year jail sentence facing obstetricians who perform what could be deemed to be a marginally illegal abortion may have unintended consequences in some cases, where even in the existing legal vacuum the decision to terminate a pregnancy is relatively straightforward.

Would the proposed legislation have helped save the life of the late Savita Halappanavar? Almost certainly not: measuring the point at which the risk to the mother’s health becomes a risk to her life remains a fine clinical judgment. And in her case, two consultants were involved in assessing the need to medically terminate her 17- week pregnancy, as now suggested in the Bill.

But the legislation does take the expectant mother’s opinion firmly into account; as such it promotes a more patient-centred model of care than heretofore.