Psychiatrists cannot always detect feigned suicidal intention
Individual’s ethical view of the status of the foetus is a factor that must be considered
The question thus arises: does this mean women could or would feign suicidal ideation in order to obtain an abortion under the proposed legislation? As to “could”– yes, but “would?” I don’t know. Even assessment by two psychiatrists does not necessarily provide the protection against unnecessary abortion it appears to provide as all psychiatrists use the same method of identifying suicide risk – with high sensitivity and low specificity. The question of whether any woman would feign symptoms in this situation is difficult. One would hope the gravity of the situation, literally the life and death circumstance for the foetus, would mean no woman would. But this is a situation where the individual’s ethical view on the status of the foetus comes into play. If the foetus is not seen as a person (or not yet) by the individual, this may lessen the deterrence from such actions.
This uncertainty in assessing suicidal behaviour may not seem to matter depending on your view of the foetus. However, this uncertainty must be considered in conjunction with what treatments are indicated. It has been repeatedly stated in the debate that “abortion is not a treatment” for suicidality. While this is true, removing stressors is an accepted treatment strategy in conditions such as depression. But often the stressors can’t be easily removed – for example bereavement, divorce or debt.
In these situations we are still able to provide treatment – identification of particular stressors is essential for effective psychotherapy. The ethical dilemma that arises is: if we are to take the Constitution’s position of having equal regard for the life of the mother and the unborn, can we see the foetus as a stressor capable of being eliminated when we have evidenced-based alternative treatments available to treat the mother?
Another concern that can interact with this uncertainty in suicidal behaviour assessment is the pervasive influence of defensive medicine. Put simply, in an area of uncertainty such as risk, with all options being equal, doctors will often go for the option that is safest medico-legally. This will favour the mother over the unborn disproportionally since successful litigation is unlikely to arise from any harm to the latter.
Dr Michael Reilly is a consultant psychiatrist. He spent two years as a research fellow in suicidology and has a special interest in psychiatric ethics.