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.

“If you terminate a pregnancy in these circumstances, you’re doing something wrong and you also would be breaking the law of the land,” says Keane.

However, medical emergencies are not static situations and it is often difficult to distinguish between threats to the life and the health of the mother.

As barrister Simon Mills points out, on the available facts, it does not appear Ms Halappanavar was facing a substantial threat to her life until after her baby was delivered.

‘Jesuitical’ distinction

An argument against giving her the termination sought therefore had a “technical, legal plausibility about it”, he says.

But Mills maintains this is a “jesuitical” distinction because “clearly, the longer her pregnancy continued, the greater the emerging threat to her life that justified a termination”.

As Keane points out, “if the mother dies and the foetus is only 20 weeks old, the foetus will die anyway”.

How does one measure a “real and substantial” risk to the life of a mother, Mills asks. And does one wait for such a threat to mature before taking the decision to terminate?

It is doubtful whether rules can ever encompass all the situations that arise in tragic, complicated medical catastrophes.

Medical Council Guidelines

The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (2009) sets out its position on abortion:

Abortion is illegal in Ireland except where there is a real and substantial risk to the life (as distinct from the health) of the mother. Under current legal precedent, this exception includes where there is a clear and substantial risk to the life of the mother arising from a threat of suicide. You should undertake a full assessment of any such risk in light of the clinical research on this issue.

It is lawful to provide information in Ireland about abortions abroad, subject to strict conditions.

You have a duty to provide care, support and follow-up services for women who have an abortion abroad.

In current obstetrical practice, rare complications can arise where therapeutic intervention (including termination of a pregnancy) is required at a stage when, due to extreme immaturity of the baby, there may be little or no hope of the baby surviving. In these exceptional circumstances, it may be necessary to intervene to terminate the pregnancy to protect the life of the mother, while making every effort to preserve the life of the baby.