Listening to the patient voice on abortion

Before Christmas, I, along with a group of mainly young GPs, met in Dublin to hear speakers including the Master of the National Maternity Hospital Dr Rhona Mahony discuss the clinical, ethical and legal issues that the Eighth Amendment of our Constitution and associated legislation pose for doctors and patients.

We were not the only grouping to gather to discuss this subject. As I write this piece, the Citizens’ Assembly, comprising 99 citizens and its Chairperson, along with a panel of selected speakers, has just met for the second of four scheduled dates to consider the very same article of our Constitution.

Subsequent to its public meetings, members will make conclusions that will form the basis of reports and recommendations that will be submitted to the Houses of the Oireachtas for further debate and may well go on to have a substantial impact and bearing upon any future constitutional change.

The organisers of our meeting, of which I was one, felt that there was a need to openly discuss an area of legislation that has generated much debate.

I had felt that apart from a few notable examples in the past, GPs had possibly not been as vocal as their obstetrics colleagues on this issue. This is striking, given that GPs take responsibility for the care of the majority of pregnancies under 18-to-20 weeks. We usually represent the first point of contact for a woman who has discovered that she is pregnant, whether this be a crisis pregnancy or a welcome event in her life.

Dr Mahony, Dr Adam McCauley, Barrister and Law Lecturer in Dublin City University, and GP Dr Marion Dyer provided respective obstetric, legal and GP perspectives on current implications for doctors and their patients under the Eighth Amendment, with reference to guidance by the Medical Council, the ICGP and the Constitution itself.

We discussed cases that have generated widespread coverage and debate, such as the ‘Ms Y’ case, which involved a young asylum seeker, pregnant and suicidal, who sought an abortion under the Protection of Life During Pregnancy Act 2013; and the tragic case of a young woman who, while 15 weeks’ pregnant and on life support following a diagnosis of brain death as a consequence of an acute brain trauma, was the subject of a High Court order following uncertainty among her treating doctors as to whether they could turn off her life support due to the constitutional position and as prescribed in the Act.

These tragic cases serve to demonstrate the far-ranging, inherent difficulties in trying to broadly legislate for scenarios that are complex and challenging for both doctors and their patients. 

There is a threat of prosecution contained within the legislation. Obstetricians have previously spoken of the ‘sword of Damocles’ hanging over physicians when making complex decisions that, from a clinical perspective, can only be dealt with on a case-by-case basis, with careful consideration for the patient’s wellbeing and rights and accepted international best practice.

Some in attendance voiced concern that some patients may not feel comfortable disclosing to their doctor that they had travelled for an abortion or taken so-called ‘abortion pills’ at home. Indeed, the Department of Health in Northern Ireland addressed this in its updated abortion guidelines this year, the language contained within suggesting a ‘don’t ask, don’t tell’ approach. This obviously raises issues of access to and continuity of patient care, and of course the bond of trust between doctor and patient.

Should GPs be concerned that their patients could feel hesitant about accessing abortion aftercare for fear of judgment or prosecution, and as a result potentially put their own health at risk? Are we certain that they feel confident that patient confidentiality is prioritised ahead of the law as it stands?

Implications of any further potential legislative change with reference to specific clauses of rape and fatal foetal abnormalities are often referenced as a potential foundation for so-called ‘abortion on demand’. 

How in a practical sense would these clauses be applied? What would the role of the GP be in such scenarios? I wonder how many GPs feel confident about accessing scarce resources such as perinatal psychiatrists in emergency situations, especially those practicing outside of Dublin or in rural settings?

The reality, of course, is that each patient and situation is unique and what ideally should be a clinical decision made with that patient is framed by a legal construct that attempts to govern absolutely that which is not absolute.

Doctors have a clear and unwavering duty in remaining as advocates and providing timely, safe and accessible reproductive healthcare for their patients. It is a fundamental duty of our elected politicians to support us and our patients by providing a clear legal framework for provision of this care in this country.

Important views will be aired at the Citizens’ Assembly, often from vastly different perspectives, but there should be a commonality of reasoning, in that we should strive to provide women with the highest standard of reproductive healthcare.

The voices of our patients may not be represented at some meetings that discuss difficult topics behind closed doors, so we, as their physicians, need to listen to them in our rooms, in our surgeries.