Dr. Bernie Mccabe on Behalf of Professor Patricia Casey

Dr. Bernie McCabe on behalf of Professor Patricia Casey

Submission on Protection of Life during Pregnancy Bill 2013

Oireachtas Health Committee May 2013

Bio for Dr. Bernie McCabe

UCD Graduate. Working since 2006 in General Audit Psychiatry in South Meath Mental Health Services.

Executive Summary

There is no evidence available suggesting that abortion is a treatment for those who are mentally ill and suicidal.

Claims have been made that some women are suicidal simply because of the pregnancy only and not because of any underlying illness. There is no scientific data on this group to assist in predicting suicide. Psychiatry has little to offer this group beyond saying that mental illness is absent.

Head 4 should be replaced by a clinical care pathway for suicidal women that does not include abortion, so that they can readily access treatment

In the event that legislation as planned progresses, there are several aspects to Head 4 of this bill and its explanatory note that require serious attention.

Submission to Oireachtas Committee on Abortion

Consideration of Heads of Bill Head 4

I will consider Head 4 of this Bill since it is the only one that relates directly to psychiatry. Head 4 deals directly with the provision of an abortion in the case of threatened self-destruction.

The underpinnings of Head 4 (to be read in conjunction with the Appendix below)

In my opinion there is no scientific evidence to support the proposition that abortion is necessary to prevent the loss of life by suicide in pregnancy either in those who are suicidal due to mental illness or due simply to the pregnancy. No studies have been carried out in this regard.

Prof. David Fergusson of Otago University, Christ Church, New Zealand is a researcher who has carried out a number of studies into the relationship between abortion and mental illness (Fergusson 2013). In the course of an interview on Morning Ireland on Tues. May 7th 2013, he stated :

I think it would be misleading for anyone to state emphatically that abortion does or does not help suicidal women. So I'm really taking a position of sitting on the fence here, saying if the research hasn't been done, we really need to adopt a neutral position on this argument, until better information is available.

I have argued in detail in the attached Appendix that suicide intent in pregnancy is almost always due to mental illness and that this should be treated in the same way as suicide intent in any situation by assessment, possibly admission to hospital and treatment that involves medication, psychotherapy or both. No research has been carried out on those who are suicidal simply due to the pregnancy. Yet the Government is proceeding as if such evidence exists.

The test that there must be a real and substantial risk to the life of the women that can only be avoided by abortion cannot be met since suicide cannot be predicted, even in those with mental illness.

In those without mental illness there is absolutely no information on the risk factors or likelihood of suicide. Since this group are not mentally ill psychiatry has nothing to offer over and above that of those not trained as mental health professionals and accordingly should not be involved. The role of psychiatrists in those who are not mentally ill has been addressed in Law (P v Kehoe 1992).

Offering a pregnant suicidal woman an abortion if she says that the pregnancy is the reason for this may seem to be common sense. However a large caution is required in this regard. Interventions that seem intuitively correct may not turn out to be so. The classic example of this is critical incident stress debriefing after trauma. It was be widely used in the 1980’s and 90’s only to be shown by subsequent research that not only did it not help in coping with trauma but it made the impact worse. The lesson in this is that interventions, particularly when the consequences are of such magnitude, are that we must rely on evidence rather than common sense. Abortion as an intervention is irrevocable both for the woman and for her unborn baby.

Conclusion: Head 4 as currently constructed should not be included in the current legislation. It should be replaced by a clinical care pathway that would assist women who are suicidal in accessing psychiatric assistance that is evidence based. Abortion as a “treatment” for suicidality is not evidence based.

And 120 consultant psychiatrists have signed a letter agreeing with the statement

As practising Psychiatrists we are deeply concerned at the Government's stated plan to legislate along the lines of the X-Case, as this will mean legislating for suicidality.

We believe that legislation that includes a proposal that an abortion should form part of the treatment for suicidal ideation has no basis in the medical evidence available.

We as Psychiatrists are being called upon to participate in a process that is not evidence based and we do not believe that this should be asked of the profession.

Any proposal being considered by the Government must be based on a rigorous appraisal of the available psychiatric research and medical evidence.

Fourteen of our colleagues who responded disagreed.

Explanatory note for Head 4 of Protection of Life in Pregnancy Bill 2013

In the event that Government disregards the above concerns and recommendations and proceeds to legislation I wish to outline my concerns about the current proposal.

The explanatory note (line 7, page 10) states that it is not necessary for the medical practitioner to be of the view that loss of life is inevitable or immediate. This in my opinion is a very low bar – how far into the future should one consider the risk to apply for? Should it be 6 months, 2 years, 10 yearsetc? This has the capacity to sweep up almost anybody who threatens suicide since a psychiatrist can never be sure that at some time in the future the person will not harm themselves despite the rarity of suicide and the problem of prediction. The tendency of doctors to err on the side of caution when suicide is threatened on the grounds that nobody can say suicide will not occur leaves this legislation open to wide use and abuse.
In line 11 (page 10) the Explanatory Notes state that three doctors are required to more accurately assess suicide intent. There is little difficulty with assessing intent or in assessing risk factors and this is something that psychiatrists have competence in. It is the prediction of when and whether that intent will be acted upon that is flawed and it is not possible to predict this. The number of doctors used cannot improve an inherently weak methodology (see Appendix).
In the last paragraph of page 11 the explanatory note says that where the unborn may be potentially viable outside the womb doctors must make all efforts to sustain life after delivery. However, that requirement does not go so far as to oblige a medical practitioner to disregard a real and substantial risk to the life of the woman on the basis that it will result in the death of the unborn…..it is a clinical assessment as to whether the mother’s life….is threatened by a real and substantial risk that can only be averted by a termination of pregnancy.

This wording is ambiguous and I want to tease this out a bit more.

The legislation as currently proposed has no time limits and abortions could be carried out up to birth on physically healthy pregnant women and physically healthy unborn babies, in women without mental illness who are adjudged to be suicidal.

Late term abortions are a major risk factor for subsequent mental illness in the woman. They are banned in most jurisdictions.

On the other hand Minister James Reilly has stated that where a baby is potentially viable it will be delivered and its life sustained. He indicated that should the baby develop physical or intellectual disability as a result of prematurity that the State will take it into care. This has potential legal consequences for the state. The whole idea of delivering a potentially viable baby prematurely in a suicidal woman is preposterous. It also ignores the reality that the reason the mother is seeking the abortion is because she does not want the baby alive. Women do not seek abortion other than to ensure that the baby is born dead and the Royal College of Obstetricians and Gynaecologists has developed Guidelines to ensure that this occurs in late term abortions. The suggestion that a near viable/viable baby would be kept alive was clearly made as a way of diluting the reality that the legislation will allow abortions up to birth.

The time limits need to receive serious consideration in respect of suicide.

The possibility that this legislation will either allow late term abortions or the premature deliveryof potentially viable infants with the attendant risks associated with this are both unconscionable prospects and induce revulsion. It points to the flaws in Head 4 of this legislation.

Relevant issues not considered in Head 4

Selection of doctors: There is no information on how doctors carrying out the assessments will be selected or on how they will consult with each other. The first doctor could potentially call on two likeminded colleagues (either obstructers or facilitators). How can this be avoided?
Exclusion of doctors:Will doctors with particular perspectives (facilitators or obstructers) be preferentially selected for the initial assessment and for the appeals panels? This has been suggested by some politicians and how will this be avoided?
Names of doctors: Will the names of doctors engaged in the assessments and in the panels be provided under FoI inquiries in respect of the annual reports?
Information for reports: It is crucial that information on age, level of suicide intent, prior treatments, gestation at time of abortion and so on is provided for the annual Abortion reports. The number of refusals and the reason must also be provided.
Reimbursement of psychiatrists: The proposed reimbursement psychiatrists are to receive for their work in respect of this legislation should be made public before the final legislation is published. As with all doctors working the public sector the reimbursements made to individual psychiatrists for this work should be made public annually.
Benchmarking before legislation:Those who say that abortion will be rare and only occasionally used need to provide information on the possible numbers of abortionslikely to take place annually. Similarly, those who claim there are large numbers of suicidal women seeking abortions elsewhere need to provide possible figures. This data must be provided before legislation is enacted so as to act as a benchmark in allowing evaluating the useand impact of this service over time.
Evidence of abortion as last resort: What evidence will the assessing doctors have to provide concerning treatments before abortion is recommended? What will the test for the adequacy of these be – for example with it be sufficient to say that the person has seen a counsellor? Will a detailed report from the counsellor have to be provided? How can it be shown that abortion is the last line of treatment? These need to be addressed in the final legislation and specified in the legislation.
Abortion as a treatment in mentally healthy people:Following from 7 above, for those who are not mentally ill but are suicidal only because of the pregnancy there will be no other “treatment”. Psychiatrists will thus be expected to recommend abortion as a “treatment” for unwanted pregnancy.The psychiatric profession should have no role in this process beyond saying that the person has no mental illness. This is an abuse of the profession in order to facilitate the requirements of the State. Psychiatrists in the past have allowed themselves be used as a tool of the state by incarcerating in mental institutions those who were unwanted, who were single mothers, who were mentally handicapped or who were political dissidents. We must not now be used by the state to duck the ethical and constitutional issues that the X case ruling raises. Under the current proposals the reputation of the profession will once again come into disrepute.

Conclusions

There is a dearth of information on the value of abortion in suicidal pregnant women and it has never been studied. The Government is acting as though there is evidence to support this.

Psychiatrists should not be involved except in so far as we can treat pregnant women with mental illness. Psychiatrists must base their practice on evidence.

Should legislation proceed as proposed there are a number of concerns relating to Head 4 that must be addressed.

APPENDIX

The purpose of the proposed legislation is to prevent suicide in those who have suicide intent posing a real and substantial risk to the life of the woman that can only be averted by an abortion.

What is suicide intent as opposed to suicidal ideation?

Passive death wishes are thoughts of wanting to be dead but without any desire to bringing this about oneself. For example “If I died in my sleep I wouldn’t mind”.

Suicidal thoughts/ideationis defined as considering taking steps to achieve this. They may manifest asthoughts of self-harm e.g. I thought I might take an overdose” or “I would like to end it all but I have no plans” or more persistent ideas.

Suicide intent is a measure of the extent to which a person wishes to take their lives and its assessment involves an evaluation of the extent to which a clear plan to achieve this has been formulated along with the person’s view of the future, personal supports and so on.

The current legislation is in respect of suicide intent as distinct from suicidal ideation (thoughts). There is little comfort in this since intent fluctuates and when a person is in crisis it may be elevated only to reducerapidly as distress falls. Its assessment depends on what the person tells the doctor and how the person behaves. Anybody having high intent should be hospitalised in order to ensure safety, to facilitate assessment of triggers and to arrive at a diagnosis and management plan.

Is there evidence that abortion prevents suicide?

There is no evidence that abortion prevents suicide.

No textbook of psychiatry or of perinatal psychiatry says this. These include:

Modern Management of Perinatal Psychiatric Disorders (2009) Henshaw et al

Seminars in Liaison Psychiatry (2012) Guthrie et al

Handbook of Liaison Psychiatry (2007) Lloyd and Guthrie

Seminars in General Adult Psychiatry (2007) Stein and Wilkinson

Comprehensive Textbook of Psychiatry (2009) Kaplan and Sadock

New Oxford Textbook of Psychiatry (2012) Gelder et al

No studies have examined the role of abortion in preventing suicide in women who are suicidal during pregnancy. In the proposed legislation psychiatrists are being involved in an assessment process for a procedure that has no research to ground it. We are being asked to decide that a woman’s life may be saved by an abortion and only by this.

Prof. David Fergusson of Otago University, Christ Church, New Zealand is a researcher who has carried out a number of studies into the relationship between abortion and mental illness (Fergusson 2013). He is a self-described pro-choice atheist. In the course of an interview on Morning Ireland on Tues. May 7th 2013,hestated the following:

In email correspondence with me on Sun. May 5th (published with his agreement) he wrote:

Hi Patricia,

Thanks for your email. In response to your comments, I think that it is drawing a long bow to claim that abortion may be an effective response to suicidal thoughts in pregnancy. As far as I know there is no evidence to support this view and claims of indirect evidence seem farfetched.

Both of these statements clearly urge caution as there is an absence of research to justify abortion to prevent suicide yet the Government is proceeding as if there is evidence that abortion helps in this.

Suicide intent in those with mental illness

High suicide intent most commonly occurs in those with mental illness such as depressive illness, schizophrenia, bipolar disorder and so on. The management of this is in the usual way, with admission to hospital for safety and assessment.The CMACE report from Britain (reports of maternal mortality) (2011) show suicide in pregnancy is rare. Overwhelmingly it occurs in women with mental illness that is under treated or undiagnosed. These reports point to the vital importance of early diagnosis and treatment with pharmacological, social and psychological interventions. These reports also demonstrate that women die by suicide in pregnancy even in countries where abortion is readily available.

Suicide intent in those without mental illness

We do not know the size of the group who are suicidal in pregnancy with no mental illness.Current data shows that around 4,000 women travel to Britain (and it is claimed also to Holland) for abortions every year. It is presumed that amongst these are women who are suicidal. However there is no data to substantiate this claim since the UK abortion figures do not include suicide as a specific ground.

No studies have been carried out on those who are suicidal but are not suffering from mental illness. So the proposal to legalise abortion in this group is being enacted in a research vacuum. For example we have no information on the risk factors for suicide in this group let alone on our ability to predict who might actually die by suicide.

Moreover the suicidal thoughts/intentions in those with no mental illness could be driven by other considerations such as having an abusive spouse or being coerced. In the recent pastI saw two such women who presented the Emergency Department of the Mater Hospital having taken an overdose. In both instances they presented as wanting an abortion. On assessment they both admitted they were happy with the pregnancy but were being coerced, under threat of being abandoned (one by a parent, the other by a partner) unless they aborted the baby. The distress of this led to the episode of self-harm. One, at the time of the overdose, had selected a possible name for the baby. With support,both continued the pregnancy and gave birth.