Acting Chairman (Deputy J. O'Keeffe): We are in public session. I would like to welcome Dr. Declan Keane, Master of the National Maternity Hospital, Holles Street, to this meeting of the Joint Committee on the Constitution in connection with its consideration of the abortion issue. The format of this meeting is that you may, if you wish, make a brief opening statement which will then be followed by a question and answer session with the members. Your attention is drawn to the fact that while members of the committee have absolute privilege, this same privilege does not in fact apply to you. The background to your attendance here is that the committee decided to invite you to come because of your position as Master of Holles Street which I understand is not just the biggest maternity hospital in Ireland but in fact the biggest in Europe with over 8,000 births per annum.

Dr. Declan Keane: Correct.

Acting Chairman: We very much appreciate your response to our invitation and I would now invite you to make an opening statement and then, perhaps, to deal with the questions from my colleagues on the committee.

Dr. Keane: My name is Declan Keane. I am the Master of the National Maternity Hospital, Dublin, which for some time has been the largest maternity hospital in Europe and the second largest maternity hospital in the English-speaking world. I have been in the role of master since 1998 but have spent time previously in training in the United Kingdom, having worked for four years in Bristol and three years in Oxford where I have been exposed to matters concerning abortion under the UK system.

I am also, in my role as master, on the executive of the Institute of Obstetricians and Gynaecologists, the main board which governs both training and legislation regarding obstetricians and gynaecologists in this country.

Acting Chairman: Would you like to make any opening remarks in relation to your views on the present issues or would you prefer to leave it by way of response to questions?

Dr. Keane: I would prefer for the time being to leave it by way of response, if that's okay.

Acting Chairman: If at any time you want to make a more expanded statement that would be fine too. On that basis I invite Deputy Liz McManus to open the proceedings from the committee's point of view.

Deputy McManus: First of all, Dr. Keane, I thank you very much indeed for attending today. We appreciate very much that your time is valuable but your time here is very valuable to us. Could I ask you about the experience of your hospital in terms of the rare occurrences where a woman's life, a pregnant woman's life, is in danger and there is a requirement to terminate the pregnancy? This was an issue that came up yesterday with the other doctors who have been here. I would just like to know what the experience of your hospital has been in those circumstances and the protocol, the procedure that you adopt.

I would ask you to maybe comment on the approach that was outlined yesterday where the pregnancy is terminated in the particular circumstances to save the life of the mother and certainly I would use the word "abortion" to cover that act. It seems to me to be abortion and certainly the medical dictionaries describe it as abortion. Do you as a practising doctor use that term? Do you consider that it is something else and, if it is, what is it? The advice that we have had by way of the expert group which looked at the Constitution very clearly states that if, for example, there was a constitutional ban on abortion this would interfere and prevent and affect current medical practice where intervention is required. So, clearly the expert group felt that abortion did cover this kind of practice and certainly it would seem to me that it does, but I would just like your views on that. Maybe if I ask you a couple of other points also, is that fair?

Acting Chairman: Yes.

Deputy McManus: Just to take less time on it. I am a graduate mother of Holles Street and I have great respect for the institution. I have noted that, since my time there, the practice and management of pregnancy and delivery has changed enormously and I would ask you in terms of the future developments and the changes that are occurring whether that is an aspect that we should be taking on board - for example, I understand that the actual techniques involved in abortion may change in the future, that it could be by way of taking a pill or whatever - and whether that has any bearing, or should have any bearing, on the work we are doing.

I ask also about the practice of the hospital at present where there is a choice to be made or where there are different options that may be suitable for individual mothers. Say, for example, with ectopic pregnancy, do ethical considerations come in where there is a choice - the doctor can make a choice between giving medical treatment to terminate the pregnancy or having to actually embark on surgical procedure? It would concern me that the best possible option of medical treatment would be available to a woman, as appropriate. Maybe you could just advise us on the practice in the hospital.

Dr. Keane: Okay, there are a number of issues you raised there. I think first of all regarding definitions, and I think one can ... it is critical always whenever anyone is discussing any topic to define what one means by it. In the medical profession we have always defined - and in the clinical textbooks - an abortion as a pregnancy that is lost in the first trimester of pregnancy. It is unfortunate that the term "abortion", certainly in the lay press, has become synonymous with the termination of pregnancy induced by a variety of means. But, as I say, an abortion is a pregnancy lost in the first trimester of pregnancy which is up to 14 weeks.

A miscarriage, technically, was the definition for a loss of a pregnancy between 14 weeks up to a period of viability of the foetus, which used to be taken as 28 weeks but which is increasingly coming down because we can now keep babies alive from about 24 weeks gestation onwards. However, I think in terms of the debate that we are having here at the moment and your committee we are talking about abortion in terms of terminating a pregnancy, and that is what I have taken it as to mean.

You started off by asking about those indications, perhaps, where medical termination of pregnancy is required in the maternal interest. I have been interested to read some of the submissions which have been sent to me prior to coming today. But there is no doubt that in my practice, both here and in the UK, there are rare but real indications where a termination of pregnancy is occasionally and unfortunately required in the best interests of the mothers. I say "rare" because I would suggest that between the three Dublin maternity hospitals, where we account for about 20,000 deliveries a year and over 40% of the deliveries in the Republic of Ireland, we probably would be talking about, perhaps, one case between the three hospitals a year.

I can get into specific details of what cases they can be but certainly in the last couple of years both ourselves and the Rotunda Hospital have had two severe cases of HELLP syndrome, a condition that-----

Deputy Enright: What did you call it again?

Dr. Keane: HELLP syndrome, which is a variant of pre-eclamptic toxaemia, a condition where the mother has severe hypertension where the liver is involved. The actual letters HELLP form a specific acronym for haemolysis elevated liver enzymes and low platelets. We had a case in 1998, as I say, where the woman was severely ill with this condition. She was transferred to a neighbouring general hospital under the care of the liver specialist and the medical opinion that we got from the liver specialist was that this woman was going to die if her pregnancy did not end. It was a very difficult decision to make. We obviously had to not only talk at length with the parents involved but with our legal team as well. But there was no other way in which this woman would have lived if the pregnancy had continued.

I think in the past, and I cannot comment too much on the past because I am one of the youngest masters in the hospital, but the hospital would have always been faced with rare but albeit real conditions like this. You have already alluded to the fact that, in the past, the surgical ... the treatment of these women would have often been by surgery. One would have done what they would have called, or perhaps termed, a caesarean section but, of course, if you do a caesarean section at 18 weeks it is not in the foetal interest because we know that no baby is going to live at 18 weeks gestation. Effectively, what predecessors would have been doing would have been a hysterectomy, or opening of the uterus.

As you say, we now have at our disposal in medical practice drugs which can induce a termination of pregnancy without a surgical evacuation or termination of the pregnancy. These drugs can either be administered, inserted into the vagina of the woman or now even can be taken orally, as you say, in the form of a tablet. Needless to say, these cases when they come up are rare and there is significant discussion that goes on at hospital level, at the ethics committee in the hospital, as I say with the parents and often involving the legal team as well.

I note that the Green Paper and indeed the submissions have talked about other possible indications which would include severe cardiac disease in pregnancy and Eisenmenger's syndrome has been mentioned. The Coombe hospital had a woman who died from Eisenmenger's syndrome only last year and I suspect that the master of the Coombe may wish to make a comment on that later on. Certainly in my experience in Oxford we unfortunately again had to terminate two pregnancies in women with Eisenmenger's syndrome because the real risks to the woman, if the pregnancy had continued, were considerable.

The issue of malignancy in pregnancy is always a difficult one because one often tries to make distinguishing features between direct and indirect abortion, and obviously at the end of the day for most of us practising in clinical medicine the health of a woman is paramount. And if a woman does happen to develop a severe cervical carcinoma in pregnancy where the only way of treating that is by a possible hysterectomy, and delay in treatment was going to compromise the woman, again we would have to consider performing a hysterectomy in those situations, but I'd have to say each case is taken on its merits. Each of these situations which I have given you, as I say, is extremely rare but they do happen.

Deputy McManus: In relation to the ectopic pregnancy, what I was asking you about in relation to that was this question of - as far as I can see, there are three options that may be appropriate, but one is simply a medicine rather than a surgical procedure, Methotrexate.

Dr. Keane: Right, but ectopic pregnancies, I think, are different. They are pregnancies that are never viable. They have a life period that will generally not exceed eight weeks, or maybe ten weeks at the most, because they are in a part of a woman's body that cannot sustain a pregnancy. It is not possible, even with current medical developments, to relocate the ectopic pregnancy back into the uterus again, so to all intents and purposes by the time most ectopic pregnancies are diagnosed the pregnancy has died in the fallopian tube anyway. And as you say, the way of dealing with it can either be by medical methods or surgical methods, and the methods can either be the administration of a drug into the woman's system, which is effectively an oncology drug, an anti-cancer drug - you can administer that drug directly into the tube itself under direct ultrasound or, indeed, laparoscopy guidance - or you very often have to perform a surgical treatment to the tube. And certainly surgical treatment on the tube is required if the ectopic has actually ruptured through the fallopian tube. If that is the situation, it is a life-threatening emergency where the woman can lose considerable blood and you do have to operate on the fallopian tube.

Deputy McManus: Could I just ask one last question?

Acting Chairman: Indeed.

Deputy McManus: Where a woman develops cancer and there is this issue of chemotherapy where the foetus is likely either to die or to be extremely badly damaged, is that woman given the option of having an abortion, not necessarily in the hospital? Is there any approach or protocol from the hospital in that particular circumstance?

Dr. Keane: The opinion and the views of the woman would always be the most important in that situation. What tends to happen in most cases of malignancy in pregnancy in my experience - again we had two cases last year where a woman required treatment in her pregnancy with chemotherapy agents - is that you invariably try to delay the administration of the chemotherapy until the baby has reached a viable age. So there will be, needless to say, on the medical front discussions between the cancer or oncology doctors and ourselves on what would be a period of viability. You would generally try and carry the pregnancy through to a period where you can deliver the foetus with a good chance of both survival and survival intact so that the chemotherapy is then given after the baby is delivered. Now this will very often necessitate the delivery of the baby ten, 12 weeks before the normal period of viability, so it is always to a certain extent a degree of a juggling act so that you are trying to prevent, as you say, the exposure of the pregnant foetus to chemotherapy.

In the circumstances where chemotherapy cannot be delayed until that period of time, then again the mother's views would have to be sought. You will have mothers who will not wish chemotherapy to be given and will take it that they will want their pregnancy to continue, albeit knowing that this could have effects on their life. You will have other mothers who would be happy for chemotherapy to be administered and will take the consequences that that may have on the foetus either directly, as you say, by causing intrauterine death of the foetus, or perhaps handicap. But, as I say, my experience in the Irish context so far has been always that we have tried to delay chemotherapy until a time when the foetus is delivered and, therefore, we are not having the problem of the foetus to consider in the administration of the chemotherapy.

Acting Chairman: Senator O'Donovan.

Senator O'Donovan: Again I'd like to welcome Dr. Keane here. Just a couple of questions. I understand from the two speakers yesterday and gauging by your comments today that in a conflict of interest situation you would obviously endeavour to save both mother and child-----

Dr. Keane: Correct.

Senator O'Donovan: -----and you would use your extreme medical abilities to ensure that would be possible; and that the only instance where termination would arise is where if something isn't done both will die but by terminating the pregnancy, be it ectopic pregnancy or cancer or whatever, you are doing it as a last resort so that at least one would survive.

Dr. Keane: Correct. I mean the cases that I've mentioned, the difficult case we had in '98 was a case that if we hadn't done something, as I say, not only would the woman have died but if she had died at 18 or 20 weeks, by necessity the foetus would have died as well. So, as you say, we ... Although I've mentioned already that the woman's life is paramount, we obviously do take into consideration the life of the baby and the mother, very much so.

Senator O'Donovan: Right. Following on from that, you mentioned, and I gather from you and I have no doubt the other people who spoke yesterday, that there is a very high ethical code attaching to obstetricians and gynaecologists. That has become crystal clear to me, as a lay person. Following from that, could I put two questions to you? One, is the existing legislation that we have, either medically or under the Constitution, adequate or do you see it as an encumbrance or, as in the question I raised yesterday, do you require clarity of the law as it currently stands? In other words, we are here, I suppose, somewhat as a political committee investigating which road we should go down - do we have a new referendum, do we try to deal with this by legislation maybe to clear up the X case. I would like your comments on the Supreme Court decision in the X case because one of your colleagues yesterday said that in his view proper medical evidence wasn't put before the Supreme Court in the X case. I got the impression that he was rather taken aback by the decision. In other words, where we are at, at present, is it unsatisfactory? And if we require clarity by way of legislation or referendum, which would you choose having regard to the current, I suppose, crisis that is facing the public and facing politicians at the minute?

Dr. Keane: In answer to your question, we, as medical practitioners in this country, are governed by the Medical Council and we do feel somewhat exposed in the field of obstetrics and gynaecology that we are not protected for these already mentioned rare cases because technically any form of termination of pregnancy or abortion is against the law of this country and, therefore, despite the serious considerations that are given to these individual cases, the technical termination of pregnancy that we occasionally and very rarely, thankfully, have to perform ... we are technically on the wrong side of law in doing so and we feel exposed in that area.

The proposed amendment to the Constitution in 1992, I think, was trying to effectively tackle this situation. I mean it actually stated, as you know, that:

It shall be unlawful to terminate the life of an unborn unless such termination is necessary to save the life, as distinct from the health, of the mother ...

And we are talking about situations where it is the life of the mother. I am not getting drawn into psychological effects which some of these previous, you know, cases, the X case and so on, have involved. I am talking about real cases where if the pregnancy continues, the woman's life is at risk. I am not talking about any other aspect of her health, and we do feel in the field of obstetrics somewhat exposed because the law and our own Medical Council at the moment are not on our side.

Senator O'Donovan: Can I take it, just in conclusion, from what you have told me that whether or not we face a referendum, which would be for the public to decide on a particular wording or whatever, if that can be agreed, do I take it that, in addition to this, to protecting yourselves professionally, you would also like to see legislation to copperfasten it and spell out clearly the exceptions that we now know medically and scientifically exist - they may be very rare - and maybe other possibilities where your profession might decide in five years time some other unusual disease might occur?

Dr. Keane: I think that is correct, we would like that. As a group, the Institute of Obstetricians and Gynaecologists looked carefully in terms of submitting its wording on its submission to the Green Paper on mentioning these specific cases but it was then felt that that actually might tie us too much, that if you had a woman with Eisenmenger's syndrome or HELLP syndrome that you are almost duty obliged then to terminate their pregnancy, which certainly wasn't what we were wishing to put forward either. As I say, I think we would like the amendment - or the Constitution amended so that in these cases that I mention there would be a degree of protection for the medical practitioners that what we are doing is done in the best interests of the woman and is medically correct to do.

Acting Chairman: Before I call Deputy Enright, I will pursue one of those issues, clarity. Do I take it that you believe that in certain rare circumstances direct abortion is necessary to save the life of the mother?

Dr. Keane: Correct.

Acting Chairman: In that situation, if there were to be an absolute abortion, would you feel even more exposed than at the moment?

Dr. Keane: Correct.

Acting Chairman: Thank you.

Deputy Enright: The answer given to the question asked is a matter of concern in that, as you said, you can find yourself on the wrong side of the law on this issue. You say the Medical Council is not on your side. We understood there was a code of ethics which are your guidelines. Could you clarify the situation regarding the code of ethics and how it varies with the Medical Council?

Dr. Keane: Our own Medical Council is essentially siding with the views of the Constitution that termination of pregnancy, for whatever reason, is illegal, and it is also a view of a considerable number of medical people - I respect their views - who, as I say, feel there is no indication where a termination of pregnancy is required to save the life of the woman. As I say, currently the Medical Council - and I haven't read the specifics of all of their guidelines to us recently - would side on the fact that termination of pregnancy is illegal.

Deputy Enright: Pardon?

Dr. Keane: Is illegal.

Deputy Enright: Oh yes, is illegal. Who prepared the code of ethics to which you adhere?

Dr. Keane: There would be a sub-division within the actual Medical Council itself that would look at ethical guidelines within general medical practice.

Deputy Enright: Yesterday, your two colleagues were both emphatic that there is no abortion at all in Ireland and that they attempt to save both lives. Do you go along with that?

Dr. Keane: I can certainly state from my experience in the United Kingdom that I would hate to see the situation in this country ever mirror what is happening in the United Kingdom where 98% of terminations of pregnancy are done so because of failed contraception. That is why I think the wording of any amendment or any referendum has to be carefully chosen so that we, I mean, are talking totally about - certainly I would be talking totally about those rare cases that I have mentioned where the life of a woman is at risk considerably if the pregnancy was continued.

One could get on to the whole other issues of foetal abnormality, which I would prefer not to. I also think it is very difficult when one gets into the psychological aspects of prolongation of pregnancy and the effects that may have on the psyche of the woman as well.

I do not agree with my two colleagues - I didn't hear their full evidence obviously yesterday - but, as I say, there are rare but real cases where termination of pregnancy is required to save the life of a woman, and I suspect that some of the colleagues of mine who are due to give evidence in front of you later on today will be saying the same thing.

Deputy Enright: You say that 98% of the cases in England where abortions take place are done due to failed contraception. I take it you were unhappy, very unhappy from what you've stated, with the situation in Britain? I take it you would be totally against such a situation developing here in Ireland?

Dr. Keane: Absolutely. Absolutely.

Deputy Enright: Senator O'Donovan more or less put it to you and I come back to it again, is it possible to provide safeguards for people in your profession through legislation, or is a referendum the most desirable approach - Professor Bonnar particularly was of the viewpoint that the vast majority of people want a referendum? That seems to be the demand, people want a referendum. At the time of the other referendums there was a fear amongst the people on one side of the fence that they couldn't trust politicians at the time. I think that was the general view at the time. Which way would you prefer to go?

Dr. Keane: I actually think that of all of the aspects of the abortion issue, the most clear-cut as far as I'm concerned is the medical issue. I think the moral and the legal issues are far more complex than the medical issues which, as I said to you, are rare, but they're real and I think we in the medical profession know what the risks are for that woman of the pregnancy continuing. We have medical literature to back us up on the significant risks in these conditions that I've mentioned. I can't comment on the general public's wish or not for a further referendum on the issue. As I say, I think there are certainly specific areas in medical practice where I would like to see some changes made.

Deputy Enright: A lot of those people who were looking for a referendum at that time were a little sceptical and worried about politicians. The same people I think at this stage are somewhat concerned as well about some members of your own profession. However, having listened to what your two colleagues said yesterday and you have said today, it will have assured a lot of people.

Dr. Keane: I think, I mean there's no doubt about it that termination of pregnancy is an abhorrent procedure. I mean even in the United Kingdom those doctors who perform it - and I never had to perform it thankfully in the seven years that I practised there - nobody enjoys doing a termination of pregnancy. In terms, as I say, of the medical profession here, I can certainly state I would think that the vast majority of my colleagues would do nothing, or would certainly not be seen to be doing anything to procure an abortion at all. They would hate to come forward and, as I say, certainly would hate to see the experience in the United Kingdom, which started off in 1957 when the abortion Act came out there for good reasons, but which soon - as I say, the waters got muddied very quickly and to such an extent now, as I say, that the current practice in the UK is that 98% of these are what they would consider social terminations, failed contraception.

Deputy Enright: Thank you very much.

Deputy McGennis: Thank you very much, Chairman. I thank you, Dr. Keane, for being here today. I had one of my deliveries in hospital----- Certainly it's a bit like a policeman, I must be getting fairly old if the master looks as young as you do.

If ever there was a case to be made for having full hearings, I think the fact that we are following on from yesterday with you first thing this morning is proof positive of it. The two previous witnesses stated categorically yesterday - and I hope I'm not misrepresenting them - but that there was absolutely no case, medical case, which would necessitate an abortion. Their definition of abortion ... I think maybe yours is a little bit ... or maybe what you say ... they were stating that what they were doing in the other cases, the ectopic pregnancies, not the very, very rare cases which you've talked about, were medical treatments and certainly weren't abortions. To my mind, and I asked both of them at the time, it resulted in the same effect, the baby's life was lost. Certainly, it does not fit in with the kind of procedure you described in the 98% of cases in England, where there is failed contraception and somebody elects to have an abortion on that basis. You have rightly described this as an abhorrent procedure and I think it is as well that is on the record from your point of view.

I asked one of the witnesses specifically why a case was made by other practitioners that there were rare cases in which this was necessitated. If I quote him correctly he said, "You'll find that those people are not involved in obstetrics or gynaecology". I think that can hardly be said in your case. I totally agree that what we need during this week is to consider the medical issues. We will have to deal with the moral and the legal issues and if it goes to a referendum the public will decide.

You have stated that you have had a concern that even the very few procedures you have to deal with at present might put you on the wrong side of the law. That is very worrying for someone in your position. I asked both of the witnesses yesterday - in fact one of the witnesses stated that he would not want any intervention which would compromise existing practice. I asked both of them if they felt that an absolute ban on abortion - I think the Acting Chairman posed the same question to you - would compromise existing practice. They both said no, it would not. Would you feel an absolute ban on abortion would, in fact, compromise existing practice, not to mention the ones that you have concerns about?

Dr. Keane: I think you could compromise existing practice in those cases I have mentioned. I think, as I have said in the past, hospitals would have dealt with these women in a slightly different way.

Deputy McGennis: Yes.

Dr. Keane: They would have performed a hysterectomy procedure and perhaps called it a caesarean section in an attempt to try and fudge the issue and avoid the legal implications of what they had just done. It is a termination of pregnancy, no matter what way you look at it. It is certainly not done for any foetal interest if you are delivering a baby before its viability. It can only be done for the mother's interest.

If you put a complete and absolute ban on abortion it would have compromised our position. As I say, in the case we had in 1998, she was transferred under the care of experienced liver surgeons and liver physicians in a different hospital. Their imprimatur to us was when they transferred the woman back to us and said to us that if this woman's pregnancy continues she will die. That was the bottom line and we were left with that scenario that we had to deal with. So, if we had a complete ban on abortion, our hands would have been tied. We would have been compromised in that position.

Deputy McGennis: Probably a question I should not ask - but if I had been in the hands of one of the other witnesses yesterday who stated categorically then that abortion would not have been a medical procedure which would have been necessary in the cases that you mention, my life would probably have been at risk, very much at risk?

Dr. Keane: Correct.

Deputy McGennis: Thank you.

Senator O'Meara: In your setting out of the 1998 situation - the woman, the mother who had a pregnancy of 18 weeks with HELLP syndrome, I think you called it - you said in the course of your remarks, that among the consultations that you had included consultations with the legal team of the hospital. Was that on the issue of the constitutional law of the country or on the Medical Council guidelines?

Dr. Keane: It was encompassing a lot of features. It was also encompassing at the time the feeling that although the mother herself realised the real risks and I think was in agreement with what we proposed and what the liver people had said to her in the general hospital, there was a feeling at the time that her partner was not in agreement with our views and, therefore, we wanted to get a legal opinion on what we could do if the mother was in favour of our course of action but the father was not. It was not primarily dealing with either the Medical Council or the constitutional feelings on it.

Senator O'Meara: I see. I assumed that it was. In fact, I was going to ask you if you did not feel at the time that the wording of Article 43.3, which gives due regard to the equal right to life of the mother would have covered a situation such as this?

Dr. Keane: Well, we certainly in the medical system would believe it should do. When I have mentioned, as I have a few times this morning, that the life of the woman is paramount we are not ignoring the life of the foetus in saying that. As I say, we are also talking, as I have mentioned already, of a condition where if the mother had died within a couple of weeks of us doing nothing, the foetus would have died by necessity as well anyway.

Senator O'Meara: Picking up on a point made by other members, including Deputy McGennis, it was put to us quite clearly yesterday, specifically in relation to the Medical Council guidelines, that procedures such as you have described in relation to this particular mother is not abortion, it is medical treatment which has the effect of ending the pregnancy.

Dr. Keane: Well here we go back to direct and indirect abortion. I think in the case of oncology and cases we have mentioned already, where you have to give chemotherapy for a woman who has a tumour or a cancer, where perhaps a by-product or a knock-on effect of that treatment is that it could be deleterious for the foetuses - that is one issue. I think where you are actually directly terminating a pregnancy, whether that be by surgical or medical means to end a pregnancy in the interests of a woman, that, to me, is termination of pregnancy or abortion in any shape or form you wish to define it.

Senator O'Meara: As you said yourself, the medical issues are relatively clear cut, but there are issues which are not as clear cut, as you mentioned in one remark the issue of foetal abnormality, for instance.

Dr. Keane: Correct.

Senator O'Meara: And also issues which have not been raised here, such as rape, incest and, as has come before the courts on two occasions, rape involving a teenager, so that the courts have in fact pushed out the whole grounds for what is considered to be a serious risk to the health of the mother by including suicide, potential suicide or the threat of suicide in the case of teenage rape as constituting a risk serious enough to the health of the mother as to allow an abortion to take place under the law in this country, that is, under the Constitution of this country.

It was put to us yesterday that suicide or the threat of suicide is extremely rare in pregnancy, in fact, evidence seems to suggest that it is less in pregnancy-----

Dr. Keane: Correct.

Senator O'Meara: -----than it would be in the non-pregnant female population. However, there have been two cases that have come before the courts and have, in effect, defined the law in this country as it applies. Does that concern you? It was put to us yesterday that it is not happening arising out of these court judgments that women are presenting in hospitals saying "I am in this situation, I feel suicidal, therefore, you know, I am asking for a legal procedure, a legal abortion under the law." Do you have an opinion on that?

Dr. Keane: I think it is more difficult to define. I am not a psychologist, I am not a psychiatrist and, therefore, evaluation of these women, where there is felt to be a significant risk of suicide if the pregnancy was to continue, would be decisions taken by clinicians other than myself. I am not saying psychiatrists cannot come to a very true and real appraisal of the risk in that woman's case, but unlike the situations I have mentioned, where, you know, we do have ball-park figures on the risks, the medical risks and the sequelae of the pregnancy continuing, it is a bit more difficult.

I think the foetal abnormality is an interesting one and I think it is one that we are concerned about, because routine ultra-sound is now common practice, certainly in all three Dublin maternity hospitals. Every woman will have a routine scan on her pregnancy between 18 to 20 weeks and we are diagnosing foetal abnormalities, many of which are inconsistent with life outside the womb. Some of these women will take the options of travelling abroad. Many in our profession would consider that regrettable because they often travel to places where the pregnancy is terminated, where no post-mortem or autopsy is done on the baby and, therefore, the ability to counsel that woman on subsequent pregnancies is reduced.

But, again, it is an even more difficult issue than the medical issues because there are a lot of anomalies that would pick up on scan that are not inconsistent with extra-uterine life, but may, nonetheless, leave the baby with serious handicap, but the child would live. But, as I say, it was once said by a well known politician in this country - it is an Irish solution to an Irish problem.

Senator O'Meara: Indeed.

Dr. Keane: And, as I say, that is the way it tends to happen at the moment. Even under the current guidelines, we are not meant to procure any information to that woman in terms of where she should go or what she can do. We, again, can tell her on the basis of the ultra-sound findings what the risks are for her baby, but, as I say, a lot of the mothers would takes matters into their own hands and travel abroad.

Senator O'Meara: I was about to put to you - What do you think would be the situation if we did not have, say, the Irish solution, the escape hatch so to speak?

Dr. Keane: It varies, again, because a lot of women, even knowing that they have a baby with a significant foetal abnormality, for religious, personal and moral reasons will not want to terminate their pregnancies and we have to respect that. In fact, because of the situation in this country we support that woman consistently throughout her pregnancy. In many cases it is extremely difficult, they carry the pregnancy all the way to term and deliver a baby that may live only for a second or minutes after its birth. But, as I say, we have to take into account - and we do - the views of every individual woman in that circumstance.

I think if we did have the facility for termination of pregnancy for significant foetal abnormality then, of course, a lot more women would be far happier to avail of it in this country rather than travelling abroad to the United Kingdom or Northern Ireland without the back-up they would get if they were to stay in this country.

Senator O'Meara: Thank you very much, Dr. Keane.

Deputy Kirk: I welcome Dr. Keane. I have two brief questions. You have partially answered the first question on the psychological condition and the degree of psychological condition where you feel termination of pregnancy would be necessary to save----- Have you any theory on that?

Dr. Keane: I don't really because, as I say, I would not be an expert in the area. Most, indeed all, of the maternity hospitals, certainly in Dublin, have a psychiatrist on staff and certainly those cases are evaluated. I know one of the people who is due to appear before the committee in the coming days or next week is an eminent psychiatrist who would be far more qualified than I to give you a view on that.

Deputy Kirk: On the rare and exceptional medical conditions which you mentioned earlier in response to a question, would the framing of a constitutional amendment cater for those?

Dr. Keane: Would you repeat the last part of the question?

Deputy Kirk: In the very rare and exceptional cases and circumstances where you believe termination would be necessary to save the life of the mother, do you feel they can be catered for in a constitutional amendment?

Dr. Keane: Yes, I do.

Deputy McManus: Would you like to elaborate on that?

Chairman: Deputy McDowell.

Deputy McDowell: Deputy McManus's question is obviously pertinent. How can it be catered for in a constitutional amendment?

Dr. Keane: I think that we were not too far away from it in 1992. It actually says that it is unlawful to terminate the life of an unborn unless such termination is necessary to save the life, as distinct from the health, of the mother. We are talking purely here about the life of the mother where the continuation of the pregnancy is going to be detrimental to the life of the mother. There are probably only two or three instances that come to mind where those cases occur.

Deputy McDowell: The existing amendment deals with the equal right to life of the mother and the foetus. You have used the term twice now - I assume deliberately - that you believe the life of the mother is "paramount". That is distinctly different, is it not?

Dr. Keane: That is true but I said that in the context ... and qualified it by saying that these cases I am talking about are cases where if the pregnancy was allowed to continue and the woman was to die, the foetus would also die. We are, therefore, not making a choice between the mother and the foetus. We are making a choice between both mother and foetus dying or saving the mother. So, I think if there was a situation----- As I say, I feel for these reasons that these rare indications from the medical point of view are quite clear-cut.

Deputy McDowell: Are you saying that there is no distinctive difference between saying that the life of the mother is paramount and saying there is an equal right to life or are you saying that in these particular cases, it does not matter?

Dr. Keane: I am saying that if there is a total and complete ban on abortion or termination of pregnancy where we would not be allowed in these rare cases to terminate a pregnancy, I would almost argue that very little consideration is given to the life of the mother in those situations.

Deputy McDowell: What I am getting at here is would it not offer greater clarity if the law or the Constitution were to clearly state that the life of the mother is paramount, to use your phrase? Is that in effect what the hospital currently does and believes? Is that your own belief?

Dr. Keane: No, because one of the unique things about obstetrics as a branch of medicine is that we are dealing with two patients - we are dealing with mother and foetus and we take the considerations of both very much into account, leaving aside the legal issues in this country. I think if one were to put into the amendment that the mother's life is paramount to the total ... I mean, when you say it like that, it almost seems to the total exclusion of the foetus. I would not----- I think that would need to be carefully worded.

Deputy McDowell: I am not trying to be clever with you. You used the phrase twice and I assumed it was not intended to be casual-----

Dr. Keane: No.

Deputy McDowell:-----and does seem to establish a ... "supremacy" is not the word I am looking for - seems to establish that in the event of a choice, you choose the mother. Is that effectively what you are saying?

Dr. Keane: Well, certainly in the cases that I have mentioned, we have taken into strong consideration the life of the mother but, as I stated earlier, that was for the reason that if we had not saved the mother's life, the baby would have died in addition.

Deputy McDowell: You say that the medical cases are clear-cut and I think I understand what you mean by that, but in a sense it is also clearly not the case because is it not true to say that most terminations of pregnancy which occur in Britain occur, at least formally speaking, because of medical reasons and are basically signed off by doctors who give medical reasons for the termination?

Dr. Keane: That is correct and the form in Britain has to be signed by two people, one of whom is generally the general practitioner or the person in the family planning clinic and the second is a doctor in the hospital in which the pregnancy is terminated. There are four reasons generally put forward as to why pregnancies can be terminated in the UK and the classic one is where a box is ticked where it is felt by the referring doctor and the doctor who carries out the termination that continuation of the pregnancy will have serious psychological effects on the woman. It is not done because of her physical health or because of a foetal abnormality. It is done because of probable or possible psychological damage to the woman in her pregnancy. They are signed off by doctors but that is purely a fudging of the issue. They are, at the end of the day, social terminations of pregnancy.

Deputy McDowell: This is really what I want to explore a little. Can we leave aside the psychological aspects for a moment? Are there cases in your experience - I assume there are but can you give us some sort of quantification - where the health of the mother, as distinct from the life of the mother, is placed in - "jeopardy" is too strong a word - but where pursuing the pregnancy to term would or could have a detrimental effect on the health of the mother?

Dr. Keane: I do not have figures on that. I think it is a very difficult thing to quantify.

Deputy McDowell: Well, based on your experience in Britain, for example?

Dr. Keane: Well, in my experience in Britain, I thankfully never had to do anything to either procure an abortion in Britain or indeed to counsel women in Britain because, being a Roman Catholic, I was exempted from doing so in both centres I worked in. I would say a very small proportion of women who have a termination of pregnancy in Britain have a significant psychological problem that would necessitate the termination of pregnancy.

Deputy McDowell: I am not talking about psychological problems. I am talking for the moment about medical problems where there is a risk to the health, not the psychological health, the medical health-----

Dr. Keane: To the physical health?

Deputy McDowell: Yes, physical health of the mother.

Dr. Keane: Very few - in percentage terms, 3% or 4% at most, I would have thought.

Deputy McDowell: Of those who ultimately end up getting a termination?

Dr. Keane: Yes.

Deputy McDowell: So, the total number of pregnancies, the number of cases where the health, as opposed to the life of the mother, would be endangered or would run the risk of detrimental effects, would be very small?

Dr. Keane: Correct.

Deputy McDowell: What are we talking about, 1% or less?

Dr. Keane: It would probably be in that region; it's certainly extremely small.

Deputy McDowell: So, the vast majority of terminations in Britain on medical grounds are for psychological reasons?

Dr. Keane: That is what is quoted in the form that is signed off.

Deputy McDowell: You used an interesting phrase earlier where you talked about "real" cases where the life of the mother was endangered. I take it that was to distinguish them from what you've just been describing where psychological damage was a possibility.

Dr. Keane: Simply because, as I stated already, the risks in these medical cases I mentioned are quantifiable in terms of medical literature which would define the cardiovascular risks to a woman of a pregnancy continuing. Psychological effects, as I say, cannot be measured in those same scales and, indeed, two or three different people----- Well, you have already heard that different obstetricians can give you different views but certainly if you get a psychological evaluation from different psychiatrists or psychologists, they can give you different views.

Deputy McDowell: Do I get a sense of a sort of medical - "hierarchy" is perhaps too strong a word - a sense of "We're real doctors, psychiatrists or psychologists are not"?

Dr. Keane: On the contrary, I have the greatest respect for psychiatrists and for the psychiatrists who work in our hospital. They play a very real and defined role. All I'm saying is that the----- I've already said that I am not a psychiatrist or psychologist and, you know, if the Constitution were to be amended to take into account a very real risk of suicide, I would certainly feel that I would not be qualified to make that judgment. I would certainly be depending upon my psychiatry colleagues for defining that risk because I certainly would not be qualified to do so.

Deputy McDowell: Can I take you back just a moment - I appreciate, Chairman, I am using a bit of time - to the medical cases? You say they are perhaps 1% or so. Would you have any ethical difficulties in terminating a pregnancy where there was a risk to the health of the mother as opposed to the life of the mother? I understand it's clearly not within the current guidelines, but would you personally - your own personal view - have a difficulty there?

Dr. Keane: I think each case is obviously taken on its merits and I think with the improvement in the standards of medical care we would in this country feel generally capable and confident of looking after most women in their pregnancy, even where they have significant medical disease going into their pregnancy.

Deputy McDowell: Most but not all.

Dr. Keane: Most but not all. I mean it has already been put on record, I think, by one of the speakers yesterday that you had in front of your committee that this country does have the lowest maternal mortality in the world, and I think that is a reflection both of the standard of the health of the women in this country and also of medical practice in this country. So that is why I have been trying to confine my discussion to date on those situations where we are predominantly talking about the life of the mother. I think the health of the mother again may be more difficult to quantify, but in most situations we would feel confident of looking after that woman and her baby and achieving a delivery without the need for termination.

Deputy McDowell: I don't want to push you, doctor, into saying something you don't want to say, but you have not, with respect, answered the question, which was, would you personally have a difficulty with terminating a pregnancy in those circumstances? You say you feel confident that you can help the woman otherwise, fine, but would you have a difficulty personally?

Dr. Keane: Yes.

Deputy McDowell: And would that be the common view of people in the profession?

Dr. Keane: I can't speak for everybody, but I think it would probably mirror the view of the majority of my colleagues.

Deputy McDowell: What I am getting at here is that a woman whose life is in danger will clearly feel very strongly that her life should be saved - or at least I presume most would - but is a woman whose health is in some way endangered but who is not in danger of death, is she not entitled to say, well, I would like my pregnancy to be terminated?

Dr. Keane: That is the reason why, as I said, I would not be comfortable to do so because I think with modern medical practice we would be able to deal with most physical health issues that a woman will face during her pregnancy without the necessity for termination of pregnancy, and I have been trying to discuss so far - earlier on - those cases where there is a necessity to terminate the pregnancy.

Deputy McDowell: I appreciate you have done that and, if I may say so, with commendable clarity. May I ask a final question, Chairman, on a completely different issue, again to draw on your experience, Doctor Keane, on the issue of rape or incest? I assume you must have had women, perhaps young women, presenting at the hospital who have been victims of rape or incest. I assume that they are given some sort of counselling at the hospital.

Dr. Keane: Correct.

Deputy McDowell: Have you experienced cases where the woman has nonetheless wanted a termination and how would the hospital typically deal with circumstances such as that?

Dr. Keane: I think they would be totally different because, unfortunately, these are situations where, again, the physical health of the mother is normal, where the foetus is generally normal, where there is no evidence of a foetal abnormality-----

Deputy McDowell: Yes.

Dr. Keane: -----and, therefore, termination of pregnancy in those conditions, as I say, we would not under obstetrical or indeed health - physical health - of the mother be happy with termination of pregnancy. You know, we are getting into a lot of other issues when we are talking about rape and incest from a moral-----

Deputy McDowell: I am simply trying to find out about what the practice in the hospital would be, and I assume this has happened where a woman has asked for termination. What would normally happen?

Dr. Keane: Generally, they would do so not so much through the medical profession because she probably would feel that we would not be in favour of it and would more often ask for advice on that through either the social work department or indeed in many of the family planning clinics rather than coming directly, in my experience, to a maternity hospital and seeking that information.

Deputy McDowell: Well, has it happened?

Dr. Keane: Not to me personally. I have never had a woman-----

Deputy McDowell: Are you aware of it having happened within the hospital?

Dr. Keane: No, I haven't, and that's being honest, totally honest.

Deputy McDowell: Thank you.

Chairman: Deputy McManus.

Deputy McManus: I just want to go back on two points. First of all, I think I heard you say that you wouldn't be giving information on abortion to women in certain circumstances-----

Dr. Keane: We would or we wouldn't?

Deputy McManus: -----because of the Medical Council, that you felt the Medical Council would prevent a doctor giving information even though there is obviously legislation in place to ensure that right.

Dr. Keane: Well, we wouldn't be ... we shouldn't be seen to do anything that would procure an abortion. I mean that's-----

Deputy McManus: No, but you did say you wouldn't be giving information. Now, there is a law to enable that right to be protected. Are you saying you reckon the guidelines actually prevent you giving that information?

Dr. Keane: Well, it's always been taken as such because even those doctors who perform routine ultrasound scanning and are specialists in this field, who diagnose an anatomical problem with the foetus that may be inconsistent with life outside the womb, would still be unhappy to forward that information to a woman, to tell her, for example, where she could go to have her pregnancy terminated.

Deputy McManus: Even though it is legal to do so?

Dr. Keane: Correct.

Deputy McManus: And you are saying that is the practice among your colleagues or are you saying you have a particular difficulty with it?

Dr. Keane: I would not generally be in a position to----- Most of the routine, or the scanning, would be done by other colleagues in the hospital, but as I say their personal views on it would be that they would feel unhappy with giving the woman that information.

Deputy McManus: There is one last question I'd like to ask and it is a more general question. I appreciate and respect fully your views, and any doctor being faced with having to carry out abortions is put in a difficult position. I presume you are not implying that, for example, your European colleagues are in any way less professional or less compassionate because they operate in systems where abortion is allowed for various reasons. In this country we have, relatively speaking, a high level of pregnancies ending in abortion - it now appears to be around 12%. That is a reality. There is another approach to simply turning a blind eye and having what I would feel are deficiencies, where women are going without necessarily having counselling, without the senior doctor and coming back with the same arrangements not being in place - the post mortem, for example, is a very good and important aspect. Do you think there is any merit in us developing a different type of policy concentrating on reducing the level of abortion, of actually facing up to what is happening anyway and having a policy where we would aim to reduce abortions among Irish women, but that we also provide for that possibility here in Ireland, because we can't shut it down completely?

Dr. Keane: If you are asking me, as I think you are, whether we need to face up to this problem sooner or later and perform terminations in this country instead of people travelling to the UK, I think that will be something that obstetricians would feel extremely uncomfortable with in this country because, at the end of the day, the people who would be asked to carry out the terminations of pregnancy are the gynaecologists in this country, and as I've mentioned already, you know, for religious, moral and ethical reasons most of my colleagues would be extremely unhappy to be asked to do so. In fact most, I am sure, would not do it. I would almost go as far as to say that even if it came under the legal and the law----- Indeed, if you take the UK, the law is that you can do termination of pregnancies and yet all of us who worked over in the UK had a moral opt out for not performing it and we didn't. I would consider that even if a legal right ... if the politicians decided tomorrow to bring in termination on demand-----

Deputy McManus: I didn't say on demand.

Dr. Keane: No, what I'm saying is that if it turned around and that this was the case I would think the vast majority of my gynaecology colleagues would be conscientious objectors to taking any part in that.

Deputy McManus: Is there the same conscientious objection to the morning after pill or the IUD?

Dr. Keane: That again is more prescribed by general practitioners and family planning clinics than it is by gynaecologists. We are generally dealing with patients once they have become pregnant and want to hold on to their pregnancy. The vast majority of prescribing of the morning after pill and intra-uterine devices would not be done in a maternity hospital setting.

Senator O'Dowd: I would just like to thank Dr. Keane for answering the questions that have been put to him. I am just trying to draw a trend between the people who spoke yesterday and yourself. Basically you have agreed - all of you agree - that where there is a threat to the life of the mother that medical intervention can and should take place. Would it make sense to list all of those, or is it possible to list all of those life threatening conditions in legislation, that will allow people the freedom to make sure that they don't feel under threat if they perform one of these operations?

Dr. Keane: We discussed at great length among the executive of the Institute of Obstetrics and Gynaecology in this country putting in those indications. Then it was - I think, rightly - pointed out by a couple of members that this in a way could tie our hands, that if a woman did have such a complication of pregnancy we would be almost duty bound to terminate her pregnancy because of the considerable risk. So, we decided 'against' in our submission on the Green Paper putting in those situations, such as HELLP Syndrome and Eisenmenger Syndrome and perhaps one or two other indications. But in our experience we could probably draw up a short list of about four or five conditions where the mother's life is at considerable risk. But, as I say, we didn't put it in because if those conditions, for example, were brought into any amendment to the Constitution you would be almost duty bound in a way to terminate a pregnancy or if you didn't terminate a pregnancy and a woman had this condition, are you then leaving yourself open to medical legal redress if that woman subsequently dies in her pregnancy?

Senator O'Dowd: The other question I have is that - we didn't speak about this yesterday - of the question of foetal abnormalities we are talking about today, where there is no possibility of independent life outside of the womb. What you said there was that some people in your profession feel they cannot counsel the mothers about this issue.

Dr. Keane: No, I didn't say that. In fact it is quite the opposite.

Senator O'Dowd: I picked you up incorrectly there.

Dr. Keane: We can and do counsel women and we support them throughout their pregnancy but what we're saying is that it is difficult for a lot of these women because they have a pregnancy. As long as a foetal heart is present under the laws of the country you cannot terminate a pregnancy and yet this woman has to live with the realisation that she is carrying a pregnancy where once that baby is born the likelihood is it's going to die within a very short period of time. We counsel and we do support those women but, as I say, in an alternative setting, in an alternative country, most of the women with these lethal anomalies will generally have their pregnancies terminated much earlier on.

Deputy McDowell: Just very briefly, Chairman, I think I...just in case I'm...wrong. I thought you said that you're not supposed to give information about termination to women in those circumstances. Is that the phrase you used?

Dr. Keane: Doctors have been uncomfortable in doing so.

Deputy McDowell: But you are allowed to do so? Do you accept that?

Dr. Keane: Well again, this is where we're looking for a degree of clarity because even when you diagnose these abnormalities, to be seen to be proactive almost in telling the woman that she can go to X centre to have her pregnancy terminated is not the right...because, as I said already, a lot of the women with these abnormalities in an Irish context for religious and moral and other reasons would not wish to have their pregnancy terminated anyway, would want to continue their pregnancy, but the option.....and that's how we've always managed these women because termination of pregnancy in our context has not been possible.

Deputy McDowell: Sorry, I'm just not clear in my mind as to what you would like to see happening in those circumstances. What is the ideal scenario?

Dr. Keane: I tried...I was drawn into it and tried to avoid it but I am more concerned, as I've stated at the outset, about the medical life of the woman in those conditions. I think foetal abnormalities are a little bit more difficult. I think there's perhaps only one or two situations where extra-uterine life is not possible and in those situations it would be useful to have perhaps some alteration to the Constitution that gives the women the ability to have that pregnancy terminated if she should so desire.

Deputy McDowell: In a hospital in the Republic of Ireland?

Dr. Keane: Agreed, and where a structured and proper autopsy could be carried out on the foetus after delivery so that when the woman comes back to her obstetrician for subsequent counselling about the implications and the risks of that happening on a future pregnancy, it can be given. The unfortunate scenario at the moment is that women with these abnormalities go to units in the United Kingdom, many of which...most of which do not perform an autopsy on the baby so the pathology back-up for subsequent counselling, indeed the psychological support of that woman, is also lacking in many of these institutions as well.

Deputy McDowell: So you think it would actually be preferable if the termination were carried out in your own hospital for the sake of argument?

Dr. Keane: I do because there were-----

Deputy McDowell: If the woman had been appropriately counselled in the circumstances in which you described?

Dr. Keane: Exactly, because it gives us the ability as obstetricians to appropriately counsel that woman on the risks and the implications that it has for subsequent pregnancies.

Deputy McDowell: I think you used the phrase again that these were rare, these sort of cases.

Dr. Keane: Well, they're less rare than the medical conditions I've spoken about

Deputy McDowell: Sure.

Dr. Keane: I mean Ireland has the second highest risk of neural tube defects in the world, in which although the risks are coming down thankfully, as I say, we would still have a significantly high figure in this country, probably about four to five women...four per thousand - I think, is the current figure - in this country would have a neural tube defect. That would either be spina bifida or anencephaly. Spina bifida is more difficult because many babies and indeed most babies with spina bifida will live, very often with a compromised lifestyle. Anencephaly is that situation where the brain has not developed and, of course, if the brain has not developed, then it is inconsistent with extra-uterine life.

Deputy McDowell: So there is again a grey area-----

Dr. Keane: Correct.

Deputy McDowell: -----where the foetus is viable in the sense that it could continue to live but the quality of life would be pretty-----

Dr. Keane: Well, it lives in-utero because the actual placenta and the mother is giving life.

Deputy McDowell: But outside the-----

Dr. Keane: Once the connection to the mother is taken away, once there is no higher centre, no brain, the foetus will not live.

Deputy McDowell: So am I getting the correct - I will finish with this, Chairman - sense of what you're saying, that in certain senses where it is in your view certain that the foetus is not viable outside the womb you would be happy enough that...in fact you would think it preferable that termination should be carried out here but in circumstances where there is some doubt or where the foetus is viable but obviously wouldn't be in good health, you think it would be preferable if the pregnancy were pursued? Is that a reasonable summary of your views?

Dr. Keane: I think we would only be happy in this country in terminating a pregnancy for a foetal abnormality if, as you say, we were 100% sure-----

Deputy McDowell: 100%.

Dr. Keane: ----- that that foetus would not live outside the womb.

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