Threat of suicide cannot be basis for abortion law
Suicide is considered to be a self-inflicted fatal act undertaken with varying degrees of self-destructive intent. Usually, suicide has no single cause but is the end point of an individual process involving several identifiable interacting risk factors.
Suicidality is a continuum ranging from suicidal ideation to attempted suicide and completed suicide – a symptom or manifestation of mental distress – not a psychiatric diagnosis in its own right, although it is frequently associated with a psychiatric diagnosis including one of depressive disorder.
It is often seen in people who are at, and beyond, the limits of what they can emotionally endure, at a particular point in time, without provision of appropriate support. Such support may involve input in several areas, including social, financial, psychological and medical support, until the crisis is resolved and the sufferer no longer presents as being at risk of suicide.
Assessment of threats of suicide in pregnancy should include comprehensive assessment in respect of the following: social circumstances, supports and needs; personality factors and coping skills; medical condition of mother and baby; and mental state examination. Psychiatrists are key professionals in assessment and treatment of suicidality.
State of psychiatry
Having regard to assessment of suicidality, the nature of psychiatry and current state of its development, by way of comparison, is such that it very frequently lacks the certainty and precision attributable to medical and surgical disciplines. Comprehensive psychiatric assessment of suicidality frequently involves more than just one interview with the patient and those providing a collateral history: it is an ongoing process that includes further interviews to reassess risk of suicide together with assessment and reassessment of response to treatment interventions.
Even following comprehensive assessment and reassessment by highly experienced and competent psychiatrists, it is not possible to confirm, on balance of probabilities, that threats of suicide due to an unwanted pregnancy will lead to completed suicide. Any perceived real and substantial threat to the life of the pregnant mother, by suicide, is not a permanent state, but rather a crisis that will resolve and is amenable to intervention.
Psychiatric treatment in pregnancy may, for example, incorporate counselling with or without the prescription of medication – treatments that may require several months in order to achieve the desired therapeutic benefit.
The above clinical realities do not lend themselves to restrictions imposed by any statute providing for threat of suicide as a ground for abortion, for example if threat of suicide in pregnancy were to be accepted as posing a real and substantial risk to the life of the mother, why should any time limit apply in respect of abortion if the spirit of such statutory provision is to save the life of the mother?
If a time limit were to be imposed on provision of abortion in such circumstances, how would this accord due recognition to the time required for comprehensive multifactorial assessment including assessment of response to treatment inter- ventions? Should statutory provision for assessment of response to treatment be dispensed with in order to expedite and simplify matters?
Assuming statutory provision for a second opinion by a suitably qualified professional in respect of the suicidality assessment process, what implications might this have for compliance with time limits, assuming such were to be provided for by statute? In the event of a “psychiatric emergency”, would the opinion of just one medical practitioner that abortion is immediately necessary to save the life of the mother suffice in order to procure an abortion?
What is the legal capacity of a pregnant mother to provide informed consent to an abortion in situations where she is emotionally overwhelmed to the extent that her judgment is impaired, and how is this addressed and over what time period? This is not a theoretical question but a common clinical reality for psychiatrists treating patients with a diagnosis of emotionally unstable personality disorder, a diagnosis particularly associated with risk of crises during pregnancy. The absence of informed consent is fertile ground for litigation.
What scope would exist for detailed review by the courts of threat of suicide as a ground for abortion when medical practitioners are of the opinion that they exist? How many medical professionals would be unable, on conscientious grounds, to comply with abortion legislation?
The preceding questions are not matters that can be summarily addressed by the stroke of a legal draftman’s pen: threat of suicide as a ground for abortion cannot be based on clinical reality or legal certainty.
* Enda Hayden is a barrister-at-law and a consultant psychiatrist