Chairman: The schedule for these hearings has been circulated to Members and I propose to proceed with the hearings as outlined in the schedule. I ask members to have regard to the following. Your attention is drawn to the fact that while members of the committee have absolute privilege, this same privilege does not apply to our witnesses - they have a qualified privilege. Members are also reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make that official identifiable.

I propose the following format for these hearings. Where witnesses have made written submissions available to us, these have been circulated to members and copies laid in the Houses. I do not propose to allow oral presentations of those submissions. Witnesses who wish can make a short opening statement which will be followed by a question and answer session with members. If no opening statement is required, we will go straight into the question and answer session. When we complete our dealings with each witness I propose to suspend the meeting for five minutes to allow the following person take their place and to decide the order of questioning for the next session. Is that agreed? Agreed.

I wish to welcome Dr. James Clinch. He is a consultant obstetrician and gynaecologist, practised at the Coombe women's hospital and was a member of the ethics committee of the Medical Council. Dr. Clinch wrote to us on 20 January 2000 and asked me as Chairman to draw to your attention that he would be grateful if he could be permitted to speak briefly to our committee. He was chairman of the ethics committee of the Medical Council from 1995 until 1999 and was involved in formulating the current wording relating to the care of pregnant women. You will find that letter on page 161 of the book which has been prepared for this hearing.

The letter has been circulated to members, laid before the Houses and circulated to the press. Absolute privilege attaches to that letter. Absolute privilege will also attach to the transcript of these proceedings which will be prepared. The format of this meeting is that Dr. Clinch may make a brief opening statement if he wishes, and I ask him to do that in view of the fact that he asked to see us. That will be followed by a question and answer session with members.

While the members of this committee have absolute privilege, this same privilege does not apply to you in your verbal statement today - you have a qualified privilege in that respect. I welcome Dr. Clinch to the committee and thank you for offering us your co-operation. I know it is very much appreciated by the committee. I ask you to make a brief opening statement outlining what you wish to draw to our attention.

Dr. James Clinch: I thank Mr. Lenihan personally for your phone call and the committee for seeing me. I have not had much time to read the brief because I only got it at the end of last week, but I've read as much of it as I could, rather quickly, over the weekend.

I think I should introduce myself first of all. I was born in Dublin but, shortly after my birth, emigrated to south Wales with my father who was a general practitioner. I was brought up in south Wales, went to school in England and then returned to Dublin to do medicine. When I qualified in the mid-1950s - 1956 - I did a house job in Dublin and then some house jobs in the North of Ireland, and then finally an obstetric job in Cardiff. I was so exhausted at the end of that that I actually joined the Royal Army Medical Corps and was in the British Army. A few months in that made me realise that I'd sooner do medicine than soldiering, and I applied to get back into obstetrics because I had a diploma, and was sent to the Far East in the army where I worked for a couple of years. I returned to Cardiff where I spent the next five years doing my basic training, starting more or less at the very bottom and working my way up.

At the end of that I did a research job and got an MD based on the pill - the contraceptive pill - following which I went to Aberdeen where I was a senior registrar. That was at the end of the 1960s, the latter part of the 1960s when the abortion Act was just coming into England and we did a large number of abortions, both in Cardiff and Aberdeen because both of them were well known for their predisposition to abortion and in fact Sir Dugald Baird in Aberdeen had been one of the people who advised David Steele when the Act was being passaged through Parliament. After I'd been in Aberdeen for 18 months I then went to Galway as a consultant and then 18 months later ended up in the Coombe as master. When I finished being master I remained on there as a consultant and into the '80s and into the '90s I worked at the Coombe as a consultant with a particular interest in the end of pregnancy, that is the induction of pregnancy and post-maturity, and with abnormal cytology and the management of the abnormal smear and cervical carcinoma in women.

My last five years I spent in St. James's Hospital as well as in the Coombe - that was in the '90s. During that time I was chairman of the institute, I was on the Medical Council and I have been on a lot of committees. I have recently retired from gynae-clinical practice, but I am still teaching, examining and I am on the board of the Coombe, so I go in there, so I still have an interest in it.

The reason I asked to see the group was that in formulating the current guidelines of the Medical Council, which was done sort of '97, '98... and we took approximately 500 submissions when we were doing this so we canvassed a lot of people and got a lot of opinions. At the same time the report of the Constitution review group had come out and I think a lot of doctors felt that this failed to make a clear difference between treating the mother who was pregnant and actually simply killing the baby. So when the guidelines were produced they used quite small words, were very specific and in fact the paragraph on the child in utero in the current guidelines is only five lines long and it is very clear-cut we thought, but then about a year later the Green Paper on Abortion appeared and this seemed to go right back and make this confusion yet again. There are various bits - talking privately I could show it to you - where I think the writer has got it mixed up again and thinks that an abortion is treatment of the woman, and in fact there is no medical condition which is cured by simply killing the baby or getting rid of the baby.

My second reason for wanting to come here is, as I say, until very recently I was an active obstetrician and for every obstetrician when they see a pregnant woman they are thinking in terms of two people - they are thinking in terms of the mother and the baby. They actually balance their care the whole way through pregnancy, doing their best for both of them, and the concept of actually destroying one just like that is anathema to them: they don't like it. Now, if in the course of treating one of them the other one happens to die, this is certainly not intended and nobody sets out to do that. You can look at early pregnancy, but you can also look at late pregnancy. I mean there are some hospitals which have double the Caesarean section rate of others and I suppose if you were a terrible cynic you could say they are subjecting women to a very serious operation in order to put the baby first. Well they are not, they are working out what is the best way in those instances of delivering the baby.

So my submission is that there is a marked difference between actually killing what is inside the uterus - simply doing that - and treating a woman who happens to be pregnant for a disease and as a result of that treatment the baby may be adversely affected. The second is that we as obstetricians certainly feel we are looking after two people.

Thank you very much.

Chairman: I wish to raise just one short matter before I ask the members to question you. You said you were chairman of the institute. I take it that's the Institute of Obstetricians and Gynaecologists.

Dr. Clinch: And gynaecologists, yes, sorry. I should have said that.

Chairman: I just wanted to clear that up.

Dr. Clinch: Yes, yes.

Chairman: We are taking Professor Bonnar later and he perhaps can deal with the institute since he is the current chairman. I'll ask Deputy O'Keeffe to start the questioning.

Deputy O'Keeffe: Thanks, Chairman. Dr. Clinch, you certainly bring a lot of experience today which we very much appreciate having before the committee. Could I get to the point that is obviously of concern to us and I am sure to many people who are interested in this subject? Are there circumstances where to save the life of the mother termination of pregnancy is medically necessary? If so, what in general are those circumstances and what is the attitude of the Medical Council to such interventions?

Dr. Clinch: Can I answer that slightly in reverse? I won't speak for the council now because I am not on it.

Deputy O'Keeffe: Okay.

Dr. Clinch: -----but the first part of the question, you are using the word "termination". Here we're in trouble because in fact if somebody is 40 weeks pregnant and you think they should be delivered, you've terminated the pregnancy, so that's why the council guidelines were very clear. They said direct and intentional killing of the baby. There are no circumstances where simply killing the baby cures the mother, none at all medically. There are circumstances where the mother has a lethal disease or a very, very serious disease where in treating it the baby might die, but I would add that all the really serious things that you read about, for example, in this, if you don't treat them, the baby will die as well as the mother, so that's where we're back to the balance that the obstetrician deals with. He or she does the best for both of them and I've actually been in a room where discussion has gone on and I suddenly realised half the room thought they were delivering the baby to save it and half thought they were delivering the mother to save her but in fact they were both along the same lines because they had a serious problem and they wanted to treat it and deal with it.

This would be something like very, very severe pre-eclampsia, roaring blood pressure at 24 weeks in pregnancy when the baby is very, very immature. Now if you don't do something, a lot of people will say "well, the mother will die" but the baby will die as well, so you end up doing something and doing your very best but you don't do what...so you do your very best between the two of them.

Deputy O'Keeffe: Could I just follow up on that? I appreciate, of course, that you do your very best in the circumstances taking into account both the mother and the unborn baby. I was deliberately not using the word "abortion" trying to...because there are connotations attached to that word and I used the expression "termination of pregnancy" instead. One of our problems in fact is that in the Government Green Paper there isn't a definition, what is an "abortion", but could I explore the situation a little further with you? When you say in the case you have described that you have to do something, could that something involve termination of the pregnancy for the purpose of saving the life of the mother?

Dr. Clinch: Well, in that particular case if you simply kill the baby there's nothing more. It wouldn't cure the problem the woman has.

Deputy O'Keeffe: Yes, so what do you-----

Dr. Clinch: You deliver the baby at the same time of course as treating the woman for the blood pressure and emptying the uterus of both the baby and the afterbirth will start...the process of severe blood pressure and everything will start to wane.

Deputy O'Keeffe: The result is that the mother generally would be saved in that situation?

Dr. Clinch: We hope the mother will do well and we also hope the baby will do well.

Deputy O'Keeffe: What would be the chances of survival of the baby in that situation?

Dr. Clinch: You know, Mr. O'Keeffe, that the more premature you are the less likely you are to survive, so depending on the maturity of the baby, the more mature it is the more likely it is to survive. Also depending on the sex, if you are lucky and it's a girl - women are stronger - there's a greater chance that it will survive.

Deputy McManus: First of all, Dr. Clinch, can I thank you very much for taking the time to come here? We've a process of deliberation now and various members of the medical profession have offered to come forward and agreed to come forward and we are very grateful for that because it is a very complex matter. I thought, as somebody who was pregnant on a number of occasions, I knew something about it but I clearly didn't until I started to read all the material and some of the questions I have may seem a little obvious but I would go back to what you have stated in terms of saving the life of the mother.

Reading the Green Paper I would ask you, do you feel it's reasonable for me to state that in certain conditions direct termination of pregnancy is needed to save a woman's life because certainly in the Eisenmenger Syndrome case the indications would appear to me that it is...the treatment is actually the termination of the pregnancy? I am interested to hear you saying that there aren't any circumstances - I hope I'm getting you right - where you save the mother's life by terminating the pregnancy because this seems to be in conflict with the Green Paper and also with some other medical submissions that have come forward. That is one question I would ask you to come back on because I think it's important. Also I would like to know if it is the case as is stated that this is the only treatment, is it available in Irish maternity hospitals where a woman is found to have this very rare condition that needs this kind of treatment, of terminating the pregnancy?

The other area I'd ask you to comment on is in the area of ectopic pregnancy where, as I understand it, historically, the practice was that there was a surgical procedure to deal with ectopic pregnancy where - and this was found to be ethically acceptable - an organ was removed or part of the organ was removed and if it happened to have the foetus in it, well that was a side effect of the treatment that now with laparoscopy it is possible simply to remove the products of conception and leave the woman intact. I don't know...I am sure you're aware of this but in the April edition of the British Medical Journal, there is a clinical review of further treatment now which is purely medical, which deals with the ectopic pregnancy without any kind of evasive surgery at all. I would be grateful if you would inform us as to whether this is an option, where it is suitable obviously. Is this an option provided for Irish women who need it or is there any question that because it is in effect killing the foetus, removing the foetus, that it is not the option provided and that the surgical option is provided for ethical reasons?

The other question I would ask you is this issue of acardiac twins where in order for one twin to...Now it is an issue that has been raised by one of your colleagues-----

Dr. Clinch: By Dr. Denham, yes. I read it. Yes, indeed.

Deputy McManus: Indeed, you know that again we are all aware that they are rare conditions but we have to ensure that the woman's life in all circumstances is protected, so this is obviously one aspect, rare and all as it is, that we must ask you. What is your view in relation to the position put forward by Dr. Denham, which is in effect, as I read it, that in order to save the twin that has the heart you must abort the twin that doesn't? Is it the kind of practice that you feel is appropriate? Does it, obviously, come within the medical guidelines?

At the moment, there is a general view about Irish people that we don't like the idea of abortion and we don't agree with it but clearly an enormous number of women, relatively speaking, are availing of the option of having an abortion in Britain and the numbers are rising all the time. Is this something that would concern you as a practising consultant, that women are choosing to have medical treatment outside of the provision here, and possibly without the proper ante-abortion treatment or post-abortion treatment, more importantly, or do you feel it is a matter of their private, individual choice?

Finally, in terms of future medical developments, it would appear to me, and maybe you could comment on this, that medical practice and clinical practice is changing and that what we now would consider, as a lay person, to be direct abortion was not carried out in the past but is carried out now in order to save women's lives and may increasingly be in the future? Do you see changes into the future? I cited the example of the ectopic pregnancy where a woman would be intact because of medical treatment now that is available that presumably wasn't available in the past.

Dr. Clinch: That is a lot of questions.

Deputy McManus: I'm sorry.

Dr. Clinch: I thought I'd get one question at a time. I will start at the beginning. I was going to start at the end but I think I'd better start at the beginning and then we'll look at the future.

I'm not a cardiac surgeon; all I do know is that if you look up the most recent maternal mortality report from England, they had three Eisenmenger's deaths in three years. One of them refused a termination and she died much later in the pregnancy, one was picked up later and she died too - these are just the deaths - but one of them came in, had her termination and went home and died two weeks later. Termination does not cure Eisenmenger's. If you review all the literature on Eisenmenger syndrome you will more or less get a headache because it is obviously riskier than having a normal heart but it would appear that the, as it were, the death rate is not inevitable amongst women and, with very, very good care, it seems to be lower than it might be and Dr. Denham quotes a lower incidence than some others.

Now, the ectopic pregnancy. You are working in a hospital, you find somebody with a tube that's swollen, bursting, about to rupture and maybe do something terrible. You're a registrar or senior registrar. You treat that woman the best way you can. Your intention in treating that woman and her tube is not to kill a baby. That's why the word intention was put in. So that's how I would look at that.

Then you have the acardiac one. In fact, that's not to save the life of the mother. It was a surprising comment. I didn't actually read it in here but I talked about it before hand. I don't know how Dr. Denham decides if he rushes into a burning house and there are two people, I don't know how he decides which one to take out first. There is a certain element of that in it but it's certainly nothing to do with the mother's life. If you care to make a judgment on whether you should kill one person instead of another one, I think that's extremely difficult.

Then you spoke about abortion abroad. Obviously, you worry about anyone having a termination, obviously there isn't a doctor in this country who wouldn't see someone and discuss what is euphemistically called a crisis pregnancy but, in fact, the first time you are pregnant, everyone, I think, is in a bit of a crisis and a bit agitated, and they would certainly see them afterwards. I can actually show you records of loads of women I've seen post-termination who've ended up in the Coombe and been looked after and nobody would refuse to look after them.

The last one you asked me was about the future. I actually do see things happening in the future which will be quite interesting. Thirty years ago, if a baby was very premature, you put it in an incubator and it quite likely died. Then we realised that if we put a tube down the baby and did its breathing for it, it might well survive. Whereas 30 years ago, babies of 34 and 35 weeks were dying, now we get very angry if a baby of 25 weeks dies. I do feel that if the human race was extremely short of people, which we're not, but if we were extremely short of people, by now someone would have designed an artificial uterus full of saline and you'd take the baby out if a woman had cancer of the cervix, you'd take the baby out, put it into this thing, plug in its umbilical cord and it would grow because we all know with ultra sound over the last 20 years that you can see a baby's heart when it is six millimetres long from head to bottom, and that all that baby needs is nourishment. That would be six weeks after the woman's last period, four weeks after she conceived and ten days or so after the period she has just missed. So we know that from very, very, very early on, much earlier than we thought, the foetus or the contents, are a competent unit which, if fed, grow into something bigger, then into an infant, then into a child, then into a teenager, then into an adult and then into an older person. There is a continuum along which your obstetricians want to give the best possible care.

The word termination, if I could come back to it a bit, it partly answers what you said, Ms McManus and Mr. O'Keeffe - it is very, very confusing. That's why we use the word kill or destruction. If you read the missives from my own college, from the Royal College of Obstetricians and Gynaecologists, it actually has a very interesting booklet published in 1996 because they are getting worried in England you see about late abortions - they call them terminations - in case the baby survives because, of course, the whole point of all these procedures is that the baby is dead. If a woman goes to England and has an abortion, and they take the baby out and hand it to her, they have missed the whole point. So, in fact, this booklet, which I can give you, or you can buy from the college, says how important it is that the baby is dead before it is born because foeticide is legal, infanticide is murder. It gives instructions in one of the appendices about the various methods of making certain the baby is dead. Obviously it doesn't use the word "kill" but kill is a very short, simple word and that's actually what they're trying to do. So, I would use the word destruction or kill and that's what a deliberate and intentional disposal of the foetus is, unfortunately.

I hope that answers your questions.

Chairman: Deputy McManus, do you want to ask further questions?

Deputy McManus: No thank you, Chairman.

Senator O'Meara: Thank you, Chairman, and may I also extend a warm welcome to Dr. Clinch today.

I wish to ask him a specific question arising out of the Medical Council guidelines issued in November 1998, which I understand from your comments that you were responsible for or partly the author of, and that you have referred to and described as clear cut - very clear cut in fact - in your opening remarks. The specific guidelines are referred to here in the publication of the Green Paper and, indeed, as you have set out yourself, treatment is given to a mother where a real and substantial risk arises and failure, indeed, or refusal by a doctor to treat a woman with a serious illness because she is pregnant would be grounds for complaint and so on. What I want to propose to you is the issue that arises and, indeed, is referred to in the Green Paper, if you want to refer to it, or to look at it, page 29 of the large document before us, that an issue does arise with regard to how the courts have seen what constitutes a real and substantial risk, specifically in the X case and the C case where the courts have seen that a risk of suicide, in other words, where a mother threatens suicide because of the pregnancy posed, in those cases as a result of rape and alleged rape, that that actually does constitute a serious and substantial risk to her health and that the courts have found that in those cases that abortion can be carried out. Does that then not conflict directly with the Medical Council guidelines? The Green Paper finds that it raises a number of questions, firstly as to the powers of the Medical Council to strike a doctor from its register in the event of a complaint of carrying out an abortion in circumstances equivalent to those of the X case, in other words, presumably where a mother presents with a risk of suicide or has threatened suicide and the doctor takes the view that that constitutes a real and substantial risk to her health and, therefore, an abortion should be carried out. In your view, how then does one reconcile this problem? To us, as legislators, and in terms of making recommendations on this whole issue, this is a very important and central point. On the one hand, the courts are saying that suicide does constitute a real and substantial risk to the health of the mother, therefore justifying or allowing an abortion to take place within the law, but the Medical Council guidelines appear to take a narrower view of that. Can I ask you your view on whether the threat of suicide by a mother does constitute a real and substantial risk to the life of the mother?

Dr. Clinch: Medicine and law make very bad bedfellows. Certainly a thing can be legal and unethical, you know that. There are some countries where they circumcise women. We would hardly think that was ethical. There are certainly countries where they amputate limbs. I would regard that as unethical. I do not really think that hanging "baddies" is ethical, or if a doctor is involved in it. A thing can certainly be legal and unethical.

One of the big problems, if I might, Mr. Chairman, just say one thing, is that the law looks backwards and medicine looks forward. We know this in many ways. Just as an aside, one of the great troubles of modern technology is that the law cannot keep up with it, and if it was not for our own in-built ethic and public responsibility standards and the way we treat other people, I do not think we would be able to deal with it at all, because the law will catch up with it and by the time the law catches up, there will be new technology. The law is not very good on these things. The law is confrontational as we practice it in these islands; medicine is empathetic, and it is different.

Now we come back to suicide. If you look at the most recent Maternal Mortality Report, it says quite clearly that pregnancy appears to damp down the tendency towards suicide. If you look at Anthony Clare's work in the 1980s - now he may have changed his mind but I have a lovely picture of him saying that psychiatrists are not very good at predicting suicide. If we look again at the English Maternal Mortality Report, we see that one woman was brought into hospital for a termination because she was going to commit suicide, and she committed the suicide before they got her down to the theatre. So it does not seem that even termination stops it. I am not a psychiatrist. That is only a general reading of it. I really think you should get a psychiatric opinion from a psychiatrist, again with due respect, not from a barrister. I do not want to be rude, and I am obviously not being rude or trying to be rude, but psychiatric opinion, from what I can see, seems to think that pregnancy is almost protective from suicide.

Senator O'Meara: I would like clarification. I want to ask again about the issue of the Medical Council guidelines and how doctors can see that in the context of suicide.

Dr. Clinch: Sorry. I gave the illustration. That lady in fact obviously needed very marked psychiatric treatment, not a termination. In the previous triennial report there were two deaths from suicide within weeks - two and five weeks, I think - following termination for psychiatric disturbance. So really, if somebody is very psychiatrically disturbed, what they need is really good psychiatric therapy. One of the problems with termination in the UK is if there is an awful lot it comes to be seen as the treatment for everything, so you get a woman coming in in cardiac failure who happens to be pregnant, so they terminate her pregnancy, and then she dies of cardiac failure. Quite a lot of that goes on, if you read these reports. The proper treatment for somebody who is psychiatrically disturbed is to treat the psychiatric disturbance not, as it were, cut a lump out of them.

Senator O'Meara: Does mental illness or a serious psychiatric disturbance constitute a serious illness under the Medical Council guidelines?

Dr. Clinch: If you are psychotic or psychiatrically depressed, it is an illness and it should be treated. I am not trying to escape from this, but I do not like talking about other specialties too much, if that is reasonable, but from everything I have read-----

Senator O'Meara: I am just simply trying to tease out if mental illness, psychiatric disturbance or a threatened suicide, for instance, in the context of mental illness, is covered by the Medical Council guidelines in relation to carrying out abortion or termination.

Dr. Clinch: The council took the view that standard medical treatment of the mother ... and termination is not actually treatment, is it?

Senator O'Meara: Does the risk of suicide constitute a serious illness in the context-----

Dr. Clinch: The risk of suicide constitutes an illness. If you came up to me and said "I'm thinking of committing suicide", I would think you were ill. I would not say "You're fine, it's a sunny day. Don't bother".

Senator O'Meara: Thank you, Chairman.

Deputy McGennis: I join in thanking Dr. Clinch for coming in to speak to us today. The first thing that is learned in the first few moments, if we did not know it already, is that although the guidelines from the Medical Council are clear, as Deputy O'Keeffe has said, we do not seem to have a very clear definition or interpretation of abortion as we are dealing with it. That is the first problem we have.

You have stated that it never would be necessary to kill a foetus in order to save a mother's life. It would be part of something else, but there will be a point at which you have tried the other interventions, medical or surgical, in order to bring down blood pressure or whatever the problem is, so you will reach a point, having gone through the medical alternatives or supports or whatever it is you are doing, at which you may have to make a decision to kill a foetus. It may happen as a result of a treatment, but surely there are instances in which it actually turns out to be a decision that has to be taken separately.

The Green Paper and the submissions which were received in connection with the Green Paper and which we have received ourselves draw a very clear line between what is described as direct and indirect abortion. The Medical Council's definition certainly would deem that kind of intervention as being indirect abortion.

It is in the Green Paper and I know you have already said it and it is clear that law and medicine are not very compatible bedfellows, but unfortunately the decisions we make will be transferred into law at some stage. If there were an absolute constitutional ban on abortion in the morning - this is probably the question everybody would hate to be asked - would you feel that people like yourself, people in practice under the Medical Council's guidelines, might be in a situation where you could not in fact perform the procedures to which you have referred? I do not mean simple direct abortion because you have stated that is not what you do and that is not what happens here. If there were an absolute constitutional ban on abortion without wording to allow for the kinds of procedures that you currently have to carry out, would you feel that your hands might effectively be tied? Would there then be a risk to the life of a mother in those kinds of circumstances?

Dr. Clinch: You have asked me about abortion and you said there was a difficulty defining it. On the understanding that we mean simply killing what is in the uterus, if we take it as that, I would not feel I was spancelled in any way whatsoever. I feel I could get on with treating my patients, all of them. In fact that is paragraph 7.23, and that was one of the ones where I thought the people writing the Green Paper were a bit confused. There were several others, but that was one of them. There is no doubt that for years people have treated pregnant women, or certainly should have treated pregnant women, with the correct therapies. If I could turn it slightly the other way round, the baby has to take its chances as well. I used to say years ago that one of the biggest hazards babies had in the city was that their mothers were breathing. Remember what it was like in the winter. It has got to take those hazards. A large proportion of our women still smoke. A large proportion drink. Once you are that human being, albeit a tiny one, you are exposed to a whole load of things which go on around you and you take your chance. If the person attached to you has to have treatment which adversely affects you, that may be hard luck on you. It would be like Siamese twins having operations on them.

These sorts of things arise and the doctor is always trying to do his or her best for both people. That is the way medicine and obstetricians have always looked at it, not always non-obstetricians because they do not actually have to do some of the procedures they expect obstetrician gynecologists to do. I would see no difficulty whatsoever in being able to look after my "patients" - meaning both lots - properly. There are procedures. You can look at things like large placental abruption and bleeding at term. I remember in the 1970s the way we managed them in the Coombe and Holles Street was different. Somebody who was a terrible nit picker would have said you might be favouring one or favouring the other. In fact it ended up that whichever way you managed them the results of large placental abruption weren't very good. We used to section them immediately. Holles Street used to wait until they had resuscitated the woman because they felt that gave her a better chance. In fact the end results from the point of view of baby survival and mother mobility were identical. As I pointed out, somebody could criticise one of the hospitals here for doing lots and lots of sections and exposing the women to risk but they feel that, in fact, this is the correct way to deal with it. So there will always be these slight balances but everyone that I know is doing their very best for both the patients under their care.

Deputy McGennis: And you would be quite confident that that would not change if there were an absolute constitutional ban?

Dr. Clinch: If there was a constitutional ban on the direct killing of the contents of the uterus that would not change my practice.

Deputy McGennis: Why would you feel that maybe some of your colleagues who have made submissions to the Green Paper and to our own committee might have reservations about that?

Dr. Clinch: Well I think some of them don't work in obstetrics and gynaecology and they do not realise this. You must remember historically the mother or the baby child thing started coming up when cesarean sections were first started well over a hundred years ago. This woman had a baby in utero and she was in labour and looked as though she would not push it out. Depending on what the man who owned the two of them thought, maybe it was better to deliver the baby and have a son and heir and let go of the wife, or maybe you should destroy the baby, as you had to then, and as is done in very early pregnancy now and the mother had a better chance of surviving. But that is all gone. That is how it arose historically. It is way out of date.

Senator O'Donovan: I welcome Dr. Clinch. Most of the questions have been asked. I do not want to go over the same issues. You have been very frank. I ask for your view on a couple of simple questions. When would you feel, in your expertise, life begins? If you take any direct interference - I understand from you that you are saying any intentional interference resulting in the termination of pregnancy is wrong morally and whatever, that is the train of thought I am getting from you - what would your views be on something, say, which I understand a lot of young people use nowadays, the morning after pill? Is it damaging to the foetus? Is it a direct attempt to terminate the pregnancy? My view from speaking to some GPs is that its use is relatively common in the last ten years as opposed to 20 or 30 years ago. What would your views be on that?

On a final point, what would your view be in relation to a woman in her late forties or maybe early fifties who would become pregnant and there is a very strong probable chance that the baby will be Down's syndrome? Where would the Medical Council stand in that situation, where somebody is facing a risk to her own health number one, and number two the likelihood of maybe a deformed or handicapped child?

Dr. Clinch: The first question, sorry, I did not write them down. What was the first one?

Senator O'Donovan: What is your view on the use of the morning after pill?

Dr. Clinch: That was number two actually.

Senator O'Donovan: Basically life, when-----

Dr. Clinch: When life begins. I frequently saw patients who said, "Now doctor, can you tell me absolutely you see something or other?" And I would say, "Look, I left my halo in the office." Until somebody proves that it does not begin at the beginning we have got to assume that it does. And when sperm meets egg we have got to work out whether, in fact, that means it begins then. I think most practising physicians would sort of vaguely assume it begins then and that is that and don't get caught up on the minutiae of travel down the tube and implantation in the uterus. So I would be quite happy to say it began at the beginning, but I am not a very very early pregnancy scientist and I haven't done work on that.

The morning after pill - the wording used was the deliberate and intentional destruction. I think that is what we said of the unborn child. If you actually believe that there is a child there I don't think you will use the pill. If you don't believe there is a child there - the morning after pill, if you don't believe there is a child there you will use it. And if you have doubts you will, in fact, go along with your doubts. So, I think that people who sincerely believe that there is a child there will not use it.

Now as for the older woman and, incidentally younger women have children who aren't well as well, this raises the whole question of what society is to do with its people who are handicapped in any way. If you are going to get rid of handicapped people in utero why not do what Lionel Arthur did and get rid of handicapped neonates and then you can expand it? I have a handicap. I have got crooked fingers. So the definition of handicap is very difficult.

Then you get on to the whole problem of quality of life of the people who are handicapped. We all know an awful lot of very very fit people who have very poor qualities of life because of various habits they have developed. I would hate to make any comment about anyone else's quality of life. I think people who are handicapped in any way need every possible sympathy and support from the start of their life to the very end. It is a big big problem and it is a little philosophical because you can, of course, train doctors to do anything. I mean, when you first do medicine you faint when you see all the blood. After a year or two you're thinking in terms of not getting blood on your socks. You can train human beings to do anything. We all know those studies of German and American soldiers. I mean the Americans thought killing Japanese was quite normal, that killing Germans wasn't quite so bad, whereas the Germans thought the killing of Americans or western Europeans wasn't such a great idea whereas killing Russians was sport. The human race can be very unsympathetic and to take it out on people who are handicapped or, indeed, to take it out on people who are infants or to take it out on people who are in utero really is very very uncivilised.

Deputy O'Keeffe: Dr. Clinch, am I right in summarising you, to some extent, that the core issue here in your book, the direct killing - there is a clear distinction between the direct killing of the foetus or the unborn baby and the indirect killing? Is that where the distinction lies and whether we are talking about-----

Dr. Clinch: Yes, that is where the clear distinction lies. As I say, most doctors can see the difference. We felt that the - I felt, that was why I wanted to come in, and please do not quote me as being the Medical Council because I am not on the council now, but that is why I wanted to come because I felt that the Green Paper got that a bit mixed up.

Deputy J. O'Keeffe: At all times as far as the doctor is concerned, it is a question of intent. If the intent is direct killing it is wrong and if the intent is to deal with the condition of the mother and this indirectly results in indirect killing, that is okay.

Dr. Clinch: Indirect death of the baby. That would seem all right. If the mother has a serious disease it must be treated. That is why the wording in the guide was very specific about that.

Deputy O'Keeffe: There are two other issues which I will put to you although they deal with the law side as as opposed to the medical side. We are sitting in the Houses of Parliament where we have to cross over. You were asked earlier in relation to a blanket constitutional amendment prohibiting abortion. Do I take it that unless that constitutional amendment allowed for the continuation of the present practice of indirect killing it could cause problems to the medical profession?

Dr. Clinch: I have in my office at home, five judgments which I collected while I was on the Medical Council and which I occasionally read to give me an excuse to have a large brandy so, I cannot answer that question legally.

Deputy O'Keeffe: Okay.

Dr. Clinch: The legal side of it I find confusing and possibly, because you asked the question, you also find confusing. It can be very difficult to deal with exactly how the various courts think on certain things: not their conclusions so much as their premises, which lead to conclusions which do not seem to follow the premises. I could not make a comment legally. I am saying that doctors see a distinct difference. If I were to do an operation on you - a very big one because you had a very serious disease - I would be doing my best for you and if you happened to die no one could say that I had actually killed you.

Deputy O'Keeffe: Fair enough. One last question since you are sitting in the seat of one of our lawmakers: If you wanted to put forward a view as to whether or how the law on abortion should be reformed, is there any particular view you would like to put forward?

Dr. Clinch: I said to Senator McGennis that I could work very happily with a law which said you must not directly kill the unborn baby. That would not restrict me in any way in dealing with any of my patients.

Chairman: Although we are in the Seanad Chamber it is actually Deputy McGennis. We are a joint committee. I call Deputy Enright.

Deputy Enright: I join the other speakers who have welcomed you here this afternoon. We appreciate your giving us your time to discuss this very important and emotive matter.

The X case has been discussed somewhat but I return to it briefly. As you are aware, the evidence in the X case hinged around a report of a clinical psychologist. I do not know if there was much medical evidence, if any, sought. The court basically dealt with the report of the clinical psychologist. You have referred to suicide as a type of illness. In the event of your having to look after the young girl and as a medical person, I take it that you would have your own assessment before you took any act in any procedure. I would like to tease out your attitude in that type of instance.

To get back to ectopic pregnancies, you said you have no intention of killing in the case of ectopic pregnancy; you must do what you can to save both the mother and child. In the middle of the treatment, does the choice arise as to what is the next step and how you will proceed when you are treating that patient? In speaking to some medical people they have felt that a decision may have to be taken that in order to save the mother one must terminate the pregnancy. That is the view of some people. I would like to know what your views are. How do you decide and when do you decide?

Dr. Clinch: You do not set out when you go to manage a thing like that with a view in your mind, "I am going to go off and kill an unborn baby". Some of you may remember, with the ectopics, the great thrill there was two or three years ago when there was a report in the British Journal of Obstetrics and Gynaecology that someone had taken an ectopic out of a tube and put it into a uterus and it had grown into a baby. That would have been very positive and it was a little bit like what I was saying to you about how, if science advances, this type of thing might happen. In fact, it turned out to be completely false and the second last president of the College of Obstetricians had to resign because he was involved in that case report. It turned out that they could not find the baby and then they could not find the mother. So, you do not set out with that in mind.

If a young woman needs treatment of any sort you would give it to her. If she needs psychiatric, or it is usually social support, you would arrange that for her and you would support her in every way. There are numerous papers to be read on both sides about the handling of pregnancy in very, very young women. Just taking the pregnancy away, taking the baby away and throwing it away does not please them all by any means. You look after her and you try to help her to produce as fit and healthy a baby as possible.

Deputy McManus: I presume you are a member of the Institute of Obstetricians and Gynaecologists, are you?

Dr. Clinch: I am, yes.

Deputy McManus: I presume you are aware that in their submission, they consider the Green Paper to be comprehensive, up to date and an objective analysis of the issues arising in the care of pregnant women? The institute obviously takes a rather different view on the Green Paper than you have presented today.

Dr. Clinch: They did not say it was accurate. That was in the original draft and someone took it out.

Deputy McManus: Well, I think they are fairly clear that they are certainly not stating it is in any way inaccurate. But maybe I could finish my point.

Dr. Clinch: I am sorry. I apologise.

Deputy McManus: Page 127. It also refers to rare complications where therapeutic intervention is required at a stage in pregnancy. I would like you to clarify because I am afraid I am not clear in my head what you are saying. In the last few minutes you said that treatment would be given to a woman. It is quite clear from the Green Paper that there are rare circumstances - and in relation to ectopic pregnancy it is not so rare - where the treatment is the termination of the pregnancy. That being the case, would it not be fair or justified to have a concern that if there is an absolute ban on abortion that the treatment that those particular women need in order for their lives to be saved would be at risk, because the treatment is actually the termination of pregnancy?

Dr. Clinch: I think the courts would have to show that the doctor set out to deliberately kill a baby. I spoke earlier to the last Senator about the fact that if you could actually take it out and put it somewhere else you would do that. It was you who asked me about the future of medicine and this type of thing may well be possible. But with what we can do in the year 2000, you have this swollen tube about to burst and you do something about it. I remember saying to somebody who was saying that was a termination, "Look, I have a lady here who came in with an early spontaneous miscarriage and she is really, really bleeding. I want to give her some ergometrine to make the uterus contract. Is that making her abort?". They looked at me as if to say, "Is it?". I said "I haven't the slightest idea but I am not going to let her die in front of my eyes". That is what happens when you are a registrar or a consultant on call and it is two or three in the morning. You do something which you consider at that time is the best thing you can do and it is very important that doctors do that. If they start getting too uptight about various things you find that people, the public may in fact suffer and that's why the guide is very keen on that and very straightforward - "The deliberate and intentional destruction..." That's why it's worded that way.

Deputy McManus: So what you are saying too is that the Constitution and legislation should ensure that doctors do have that particular judgment that they can exercise.

Dr. Clinch: Golly, if it got established that there were all sorts of legal things - I don't think that it's just obs and gynae which might be in a bit of trouble - we might have a thing about intensive care and there would be a thing up on the wall, "It is the law that" people over 90 should have their tubes taken out after 12 hours and so on down and the Chairman would probably get about 76 hours of resuscitation, so you've got to be very careful, you've got to leave some leeway to doctors in that respect and I don't think the law would be very good at defining that. Sorry, you have trapped me into talking about the law and I really should take most of that back. I am not a lawyer.

Chairman: Are there any further questions from the members? There are just one or two short questions I want to put to you-----

Dr. Clinch: Yes, thanks.

Chairman:-----and they do relate to the law. The first point was really the Constitution and the statute law that the people or ourselves as representatives of the people enact here. That has to provide a framework within which the standard medical treatment can take place. Isn't that right? You don't want to see the law interfering with your clinical judgment and your capacity to make clinical judgments, I take it.

Dr. Clinch: Not in detail.

Chairman: Not in detail. Again sticking just to one legal matter - the Medical Practitioners Act of 1978 - I take it the ethics committee of the Medical Council is established under that.

Dr. Clinch: Yes.

Chairman: And their function is to prescribe ethical guidelines for the profession?

Dr. Clinch: Yes.

Chairman: And any breach of those would be ethical misconduct on the part of a doctor?

Dr. Clinch: Could be.

Chairman: Could be, depending of course on the judgment taken by the fitness to practise committee on the facts established in a particular case.

Dr. Clinch: Yes.

Chairman: So those guidelines would apply to - I want to choose a word - any procedure in relation to an expectant mother? Any procedure carried out falls within the scope of this guideline. Isn't that correct?

Dr. Clinch: Yes.

Chairman: It doesn't matter whether we are talking about a psychiatrist or an obstetrician or a gynaecologist - whatever the particular speciality is the guideline does apply to all procedures in connection with an expectant mother.

Dr. Clinch: Yes.

Chairman: You can bear with me for a few minutes on this, I take it.

Dr. Clinch: I can, yes.

Chairman: But the guideline is clear - it's on page 29 of the brief book - the guideline provides that "The deliberate and intentional destruction of the unborn child is professional misconduct" and "Refusal of a doctor to treat a woman with a serious illness because she is pregnant would be grounds for complaint and could also be considered professional misconduct" and "Should a child in utero suffer or lose its life as a side effect of standard medical treatment of the mother, then this is not unethical." The crucial question then of course is what amounts to standard medical treatment for the purpose of the application of that guideline. Is that a fair comment?

Dr. Clinch: I think so, yes. Before you go a lot further, I don't mind talking about this but I feel a little bit - you have Gerry Bury next week and he is president and I don't want to cut across him. I have been trying to get hold of him all weekend and unfortunately I couldn't because I wanted to say to him that there were two things I wanted to talk about, one was the clarity which I felt the Green Paper didn't have and the second thing was the view of an obstetrician.

Chairman: Yes, I-----

Dr. Clinch: I can't speak, Mr. Lenihan, for the present Medical Council. It would be unfair of me-----

Chairman: No, you don't-----

Dr. Clinch:-----because I am not on it.

Chairman: You don't have authority there and I accept that-----

Dr. Clinch: No.

Chairman:-----and you are not being taken as having authority there by the committee. What I am anxious to establish is the meaning and as you are an author - a part author of the guideline-----

Dr. Clinch: One of 26.

Chairman:-----one of 26 but a person who played a part in that process and an important part clearly-----

Dr. Clinch: I was on it.

Chairman:-----to simply give your assessment. It brings me to the very unusual condition, the Eisenmenger case which has been referred to already in the questioning. The Green Paper suggests that-----

Dr. Clinch: There is "a window" and it doesn't give a reference.

Chairman: Indeed, and it suggests that there is a clinical view that termination may be required or at least it is a clinical option which should be operable in such a case.

Dr. Clinch: Actually - while you are looking it up - termination of pregnancy can be an option for anyone. It obviously is in the UK where 26% of maternities, as it were, are terminated and in some ways society over there is quite happy with it because it removes an awful lot of the social problems. You are back a bit to terminating abnormal babies and then those of a lower social class.

Chairman: At page 12 of the brief book prepared for this hearing-----

Deputy McGennis: Sorry, Chairman, just on the last point that you made about the 26% - I probably should not cut across - I don't know if you are saying on the record that the 26% would reflect society dealing with the handicapped or those of a lower social order. That's not what you are saying surely.

Dr. Clinch: No.

Deputy McGennis: No, I misunderstood you.

Dr. Clinch: I am sorry, I was saying that there was a huge number and society over there seemed quite happy about it.

Deputy McGennis: But you did make specific reference to the-----

Dr. Clinch: Sorry, I didn't mean to put the two together. I just followed on that nobody in that society bothered very much about inter-uterine life.

Deputy McGennis: No, it just seemed to be a huge leap to make that 26% of-----

Dr. Clinch: Sorry, I was talking while I was looking up.

Deputy McGennis: Okay. With the literature which we have given I don't think even we could make that leap.

Dr. Clinch: No, I didn't intend to.

Chairman: I just wanted to relate the guidelines to Eisenmenger's syndrome, a syndrome where you have a cardiac disease with pulmonary hypertension in pregnancy. It is a very rare condition. I think that is acknowledged in all the literature but it is a condition that can develop. At page 12 of the brief book the Green Paper says that, "Clinicians consider that there is a high mortality from this condition and some recommend an elective termination of pregnancy to protect the life of the mother." In the standard medical practice referred to in the Medical Council guideline, is that a clinical judgment that is permitted under the guideline?

Dr. Clinch: No, because if you deliberately destroy the baby, that's considered unethical. If you read the whole of paragraph 1.16 it gives lots of references the other way round.

Chairman: Yes, I accept that-----

Dr. Clinch: I can only depend on the references they give; I am not a cardiologist. You would have to have a cardiologist to talk about that.

Chairman: I accept that but still there is a diversity of clinical view on this question disclosed in the Green Paper. Do you accept that?

Dr. Clinch: It says, "It is further considered that there may be..." That's two ifs and once you get to more than one if in a scientific study you are really losing it. It then says, "more likely..." As I told you, in the most recent maternal mortality report - just to go down to the medicine of it - Eisenmenger's does produce pulmonary hypertension but you can get primary pulmonary hypertension anyway and there is an additional death after termination for primary pulmonary hypertension, so it may not even be good medical practice. One of the criticisms about the whole management of heart disease in the last maternal mortality report was that perhaps some of them should have been - their cardiac condition should have been treated first and then thoughts given to something else. That's the view that would be taken in this country - somebody with a bad heart condition should be looked after by a really good cardiologist in conjunction with a obstetrician if they were pregnant.

Chairman: Suppose that obstetrician in Ireland formed the opinion that surgical intervention which would have the side effect of harming the foetus in utero had to take place to safeguard the mother's life, would that clinician be protected under the present guideline? Would he be acting-----

Dr. Clinch: I think you've put it obliquely which might, incidentally ... I think you started off by saying to me if he decided to simply kill the baby, or she decided to kill the baby ... I think that would probably be considered unethical. As I say, I am not on the council. I am not on the fitness to practise committee.

Chairman: I appreciate that but I am putting it now obliquely. Would it be considered unethical if he didn't have that intention but that his primary intention was to safeguard the mother's life - or her primary intention?

Dr. Clinch: If he did what you're suggesting, I think it would be unethical because his intention in doing it would be to kill the baby. If he said it ... if he said, "I am going to treat this Eisenmenger's by killing that baby".

Chairman: That's how I put the question initially. But suppose I reformulate it obliquely and say that the primary intention, or his or her primary intention, was, in fact, to safeguard the mother's life. In that situation would the clinician be within the guidelines and protected?

Dr. Clinch: If he deliberately and intentionally destroyed the unborn child I think he might have a question to answer.

Chairman: Under the present guideline?

Dr. Clinch: Under the present guideline. That's how it's written, so I'm interpreting it from the actual words. I'm just reading them. I'm not even interpreting them. You can read them as well.

Chairman: Yes, but suppose the consultant takes the view that the risk of mortality in this case is so great that there is no option available to him to safeguard the mother's life other than to carry out a procedure which has, as its indirect effect, the ending of the life of the unborn? Is that within the guideline or not?

Dr. Clinch: I think if you add up all the references under that chapter, there seems to be ... I mean you can do a count. We're getting right down to the head of the pin now.

Chairman: But this is the difficult one.

Dr. Clinch: You can do a count of references that some people are saying that ... some people give much better figures than others. Most reputable units would look after the woman and her heart disease. That would be the practice.

Chairman: So you're saying the standard treatment excludes that option. Effectively, that's what you're saying.

Dr. Clinch: Killing a baby isn't treatment.

Chairman: I accept that and you've made that very clear.

Dr. Clinch: You can't go further than that. You can go round and round this but if you want to be direct that's the sort of final statement on it. I should add to Miss McManus that Professor Bonnar is following me and he will speak to the institute's submission, obviously. I don't want to cross him either.

Chairman: In the treatment of ectopic pregnancy clearly you rely on the dominance of the good intention there. That's the key factor there. Is that a fair summary of your evidence?

Dr. Clinch: You must take into account intention. I mean, if I walk up to you with a gun and shoot you, that's intending to kill you quite clearly. However, if you attack me and in the resulting fracas I manage to push you down the stairs or you fall over me and go down the stairs and kill yourself I didn't intend ... I mean that's different. I mean the courts would see that. So there is always some intention in any act.

Chairman: Just returning to the acardiac case which you mentioned in the course of your evidence and which Dr. Denham mentioned in his written submission. That acardiac case, as you rightly say, involves a choice between two unborn lives rather than a choice between the life of the mother and the life of the child. If I could put it that way. But, in the case of the acardiac instance, what is the ruling? What is the position of the Medical Council? Perhaps I could reformulate it. What is the position under the guideline?

Dr. Clinch: Deliberately killing a baby in utero is considered unethical. Now, I'm not a paediatric cardiologist, Dr. Denham is and I've never seen one of those. So, I really ... it would be very difficult for me to make a comment on the clinical situation because I've never seen one and I've never dealt with one. You're getting me to talk about other people's specialities and if there are any of them in this room they'll be hopping up and down. Dr. Denham would not like me speaking about cardiology or paediatric cardiology.

Chairman: We'll pass on from the acardiac case but it does raise a very important ethical question in that particular context.

Dr. Clinch: But, Mr. Lenihan, from the day you start doing medicine you have ethical problems all the time. I've had people ask me about doing obstetrics and isn't it awful having to get up at night. I said that that's easy compared with some of the ethical and social problems you run into. You run into these every day.

Chairman: Yes, but the guideline is very general in character but are there any specific rules of guidance or rubrics for doctors which clarify the application of the guidelines in concrete instances?

Dr. Clinch: Yes, you preserve life and promote health. It says that on a couple of occasions in them. If you have a medical practice which doesn't do that you can be in big trouble. What would you do if you walked into a surgery and a doctor had a big sign up behind his or her desk saying, "I am anti-life"? You might leave.

Chairman: Yes, but in the present context of the present guideline which is, as you say, a clear-cut guideline, but it still has to be applied in different circumstances like any legislative instrument. It has to be applied to particular sets of circumstances.

Dr. Clinch: Yes, but the law will come. I mean, you will propose or not propose some legislative change. As I said, there can be differences between ethics and the law. Is this not so?

Chairman: Yes, but the ethical guidelines have statutory force under our legislation in this State.

Dr. Clinch: As far as the Act has, but you can go down to the courts and appeal them. Can't you?

Chairman: You can but I would anticipate that the ethical guidelines ... a doctor could be brought before the fitness to practise committee for any breach of the ethical guideline that we've been discussing this afternoon. So that's a legal-----

Dr. Clinch: And he might go down to get the ... we've all seen cases go down and have what the fitness to practise committee say modified or changed. The Act is, what, 22 years old and doctors still have to go down ... in fact, sorry, the fitness to practise has to go down to confirm its decision.

Chairman: Just one other question which arose this afternoon was the whole question of suicide. I think the question that was posed was, can pregnancy of itself increase or decrease the risk of a suicide? Have you a judgment to make on that as a person with considerable experience in obstetrics?

Dr. Clinch: I am not a psychiatrist, thank God. They have a very difficult job. All I know is what I read in the references and if I could read you an extract which I accidentally found on the Internet. It goes as this. It's the last maternal mortality report and the sentence is, "The most striking fact is that despite the clearly elevated rates of mental illness in child bearing women, (which I didn't know) the risks of completed suicide and of self harm are markedly reduced". That's page 3 of chapter 12 in the 1994-6 report. It then goes on to say ... I mean pregnant women do commit suicide. Lots of people commit suicide of all ages but it says here that the presence of a young and dependent child is, therefore, probably protective against suicide. Now, that's as far as I would go because I'm not a psychiatrist. I think you have ... I think some of the other people coming in are psychiatrists.

Chairman: Yes, but of course a psychiatrist would not be involved in carrying out any procedure in connection with a pregnant mother. Isn't that correct?

Dr. Clinch: Well, a psychiatrist might be asked to see a pregnant mother obviously. But I obviously read the maternal mortality reports. The reason I've only got this extract is that I haven't got the most recent report. I've got the one before it with me but this came up when I was looking up something else.

Chairman: We've taken somewhat longer than we anticipated and I do want to thank you very much for your assistance.

Dr. Clinch: I'd like to thank you. Could I just say one thing to finish with? I do think society and women in this country actually do respect intrauterine life. As you know, a lot of people miscarry and if you look at the number of people who turn up to the miscarriage clinics, if you look at the number of people who make careful arrangements for the burial of miscarried babies or miscarried remains, whatever you would like to call them, obviously there is great respect for intrauterine life, and it would be very nice if that tradition was continued. It might look as though Ireland is out of step with a lot of other countries but, in fact, we all know some other countries where they treat pregnant women and, indeed, intrauterine life very very badly, but here they respect it a lot and I think it is quite important to realise that. Thank you very much for seeing me and for all your hard work on such a lovely afternoon.

Chairman: Thank you, Dr. Clinch.

Dr. Clinch: May I stay for the next session, if that is possible?

Chairman: You can indeed.

Dr. Clinch: Thanks.

Chairman: We will suspend the hearing for five minutes.

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