Abortion case raises a number of clinical dilemmas

As the account of the young woman who had her baby delivered by Caesarean section having previously requested an abortion emerged in an interview with this newspaper, a number of clinical dilemmas have come to light .

The case also offers some insight into how the Protection of Life During Pregnancy Act 2013 operates in practice.

Under the legislation a group of three doctors make an assessment of suicide ideation, 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.

In this case, the woman has said she attempted to take her own life when 16 weeks pregnant. But she was over 20 weeks pregnant when she saw a GP and was referred to hospital.

A panel of doctors was convened and reportedly reached a unanimous decision that there was a real and substantial risk to the young woman’s life from suicide.

However, the consultant obstetrician seems to have then advised that as the baby had reached a stage of pregnancy when it was likely to have a viable future, a termination was no longer appropriate and that a Caesarean section was the correct intervention.

Following initial resistance from the woman, a section was eventually carried out with her consent.

While the assessment of suicide risk, with no objective test available, can prove challenging, in this case there was unanimous expert agreement.

Fears that suicide would be a grey area for doctors in working out when there is a real and substantial risk to the mother under the new abortion legislation did not come to pass on this occasion.

Guidelines issued to doctors advise that, where it is decided that a woman’s condition does not meet the test set in the Act, she shall be informed of the decision and told that she may explore other treatment options under the care of the existing treating team, seek a referral to another specialist or apply for a formal medical review.

The issue of viability adds another layer of complexity in this case. It is unclear whether having met the suicidality test, but was then deemed to be too advanced in her pregnancy to undergo termination, she was entitled to request a formal medical review of that decision.

In addition, pregnant women who are refused terminations under the Protection of Life During Pregnancy Act have a constitutional right to challenge the decision in the courts. Which begs the question: was the final decision not to offer this woman a termination made outside the Act, or was the legal process still underway when a Caesarean was recommended instead?

A separate ethical dilemma is presented by the decision to deliver a child at 25 weeks gestation.

While the chances of survival are good, the risk of morbidity linked to premature birth is considerable. Just one in five of these babies will emerge without some health consequences; respiratory and gait difficulties and life-long learning problems face up to 80 per cent of babies born at this gestation.

And Caesarean’s are not without risk to the mother, with haemorrhage and post -operative infection the principal complications.

Notwithstanding the wide variety of opinions on the Act, most parties will agree that on this occasion it failed to offer guidance to doctors on the most appropriate response to a request for termination that is made on the cusp of viability, when a pregnancy approaches 24-weeks gestation.