Risk of suicide may be higher after abortion

While attempting to write this column, I have found myself haunted by an image of another woman at a keyboard, who is searching the internet in a kind of bleak numbness, looking for strangers who are willing to help her end an existence which has become intolerable. The heart shrinks from imagining the desolation which prompts such a search.

This Dublin woman does find two complete strangers who volunteer to act as her messengers of death. It is unlikely, although they have accepted a fee, that these two are completely mercenary. It is possible they are in search of some perverted thrill which comes from flouting one of the last great taboos, the injunction against self-destruction or assisting others in their attempt to die.

However, it is most likely they believe they are acting out of compassion and the belief that this woman has the right to choose to die. Even among those in favour of euthanasia, most would draw the line at assisting somebody who is deeply depressed, but they do not. They are simply honouring her choice.

If my surmise about the motivation of the two who assisted a Dublin woman's suicide this week is correct, they illustrate for us, in the starkest possible way, that compassion and choice are not always the ultimate values. Honouring choice must be subordinate to the welfare of the individual and society if we are not to descend into anarchy. Sometimes people in pain make the wrong choices.

Suicide is a highly complex and difficult area, and not just in these grim circumstances. We will hear it discussed over and over in the context of abortion during the coming weeks. Those who oppose the rolling back of the X case decision are motivated by compassion, by an abhorrence for the needless loss of life involved in suicide. They are appalled by what they perceive as the callousness of those who would "force" a woman to carry an unwanted pregnancy to term, and adamantly in favour of a woman's right to choose in such circumstances.

It is not my intention to draw some kind of crude and offensive parallel between those who assisted the Dublin woman in her suicide this week, and those who oppose the rolling back of the X case decision. Rather, I am ranging them on the side of those who would abhor the loss of a woman's life, and who feel that everything should be done to preserve it, even if it means acceding to a request for abortion. But since they are motivated by compassion, there is an enormous onus on them to ensure that it is an informed compassion.

Sometimes what seems instinctively to be the compassionate choice turns out to be, on closer examination, not so simple after all. We would like to think that if a woman is in despair because of pregnancy that allowing her to end that pregnancy will also end the despair. It is not so simple. In one case I am aware of suicide attempts did not end after an abortion, even though the conception took place in horrendous circumstances. Nor did depression lift. Instead, it intensified.

What if abortion, instead of being a treatment for suicidal tendencies or for depression, carries with it significant risks of exacerbating suicidal tendencies and of causing depression? This is so serious a possibility, that anybody who believes themselves to be compassionate must take it into consideration.

None of us can predict who will commit suicide. This is the medical evidence given to the Oireachtas Committee Hearings on abortion. To say, perfectly accurately, that the rate of suicide among pregnant women is far lower than in the general population is not to say that it is non-existent. But crucially, abortion, far from being a treatment for suicidal tendencies, may actually add to them.

Dr Anthony Clare, who is in favour of abortion on different grounds, declared at the abortion hearings he was sorry that the X case judgment was given on the grounds of suicide, because: "Clearly there wasn't a real and substantial risk, and there wasn't a probability that the 14-year-old girl would have gone on to commit suicide." Dr John Sheehan, one of the leading psychiatrists dealing with pregnant and post-natal women in Ireland, said termination was not a treatment for suicidal tendencies. Both Dr Clare and Dr Sheehan cited a major Finnish study, which indicated that the risk of suicide was higher after an abortion than it is after a completed pregnancy. The suicide rate associated with birth was 5.9 per 100,000 births, half the rate of the general female population. The suicide rate associated with abortion was 34.7 per 100,000 abortions.

Some have disputed the findings of this study, or more accurately, have disputed an interpretation which implies that abortion is the sole cause of increased suicide risk. The authors, Mika Gissler et al, never said this.

Instead, in their paper they said there were two possible explanations for women's increased risk of suicide after abortion: "Either induced abortion has negative effects on mental health or both induced abortion and suicide have common risk factors." The authors could not draw conclusions from the data as to whether abortion in itself was the cause of deteriorating mental health, but they were clear that suicide risk was higher after abortion. They state: "Regardless of aetiology (cause), our study indicates that some women are at risk of suicide after an induced abortion. Overall, suicide is rare after an induced abortion, and for many women abortion may be an answer to their current problems and a relief. But some need special support, and it is the task of healthcare staff to be sensitive and to identify those women. Rather than being a relief, an abortion for them may be additional proof of their worthlessness and might contribute to suicidality and to the decision to commit suicide."

We already know that among those most at risk of deteriorating mental health after an abortion are the young, and those who have a previous history of depression. Given this knowledge, can we still be confident that abortion is the compassionate answer in the case of declared suicidal intent?