Tragic case demonstrates moral minefield faced by doctors

ANALYSIS:Decades of controversy and the lack of guidelines ensure that the treatment of pregnant, sick women in Irish hospitals remains a moral and practical minefield for doctors.

Under the Constitution, abortion is allowed in circumstances where there is a “ real and substantial risk to the life, as distinct from the health, of the mother, which can only be avoided by a termination of the pregnancy”. Successive court judgments have shown up the limitations of this article and the Government has been slow to provide more precise guidance in the form of legislation. This will happen only after it considers the report of the expert group on abortion which delivered its report this week.

Life-and-death decisions

In the meantime, doctors must make life-and-death decisions affecting both mother and foetus, knowing that a wrong call may feed into the fevered debate on abortion.

Even the Medical Council guidelines seem contradictory, saying that every effort to preserve the life of the mother should be made in exceptional circumstances, where “there may be little or no hope of the baby surviving”.

The only good news in all this is that cases where the mother’s life is endangered and can only be saved by a termination are extremely rare. Ireland has a very low rate of maternal mortality, at about six deaths per 100,000 births.

Declan Keane, obstetrician at the National Maternity Hospital in Holles Street, Dublin, points out that most miscarriages occur in the first trimester of pregnancy.

At 17 weeks pregnant, Savita Halappanavar was already in her second trimester and the general outlook for a woman at such a stage of pregnancy would be positive. Even in cases where heavy bleeding was occurring, Keane says it should prove possible to stabilise the mothers and ultimately to deliver a healthy baby. The focus of doctors will always be on the health of the mother they are treating, according to Prof Fionnuala McAuliffe, spokeswoman of the Institute of Obstetricians and Gynaecologists.

“A pregnancy will be delivered in a situation where the mother is very sick and it is felt the risk to her life might increase by continuing the pregnancy,” she says.

In circumstances where a woman has, for example, pre-eclampsia or unstable blood pressure, a decision may be taken to induce delivery of a baby in order to improve the health of the mother.

However, babies born before 24 weeks’ gestation will not normally survive.

In situations where the mother’s life is not at risk, obstetricians say the law is clear. “If the situation is not life-threatening, termination of pregnancy cannot be considered,” says McAuliffe.