Chairman: We are now in public session. I would like to welcome Professor Walter Prendiville of the Coombe Women's Hospital to this meeting of the Joint Committee on the Constitution. Professor Prendiville, we've asked you to speak to us today. The format of this meeting is that you may make a very brief opening statement if you wish, which will be followed by a question and answer session with the members. I want to draw your attention to the fact that while members of this committee have absolute privilege, this same privilege does not apply to you. A transcript will, however, be prepared of what you say and when published, that transcript will have absolute privilege. So I'd now ask you to make an opening statement.

Professor Walter Prendiville: Okay, thank you very much.

Chairman: Sorry, perhaps you had better start by stating your qualifications and experience and then the points you wish to make to us.

Professor Prendiville: My name is Walter Prendiville and I'm a consultant gynaecologist in the Coombe Women's Hospital and in the Adelaide and Meath Hospital in Tallaght. I am a Fellow of the Royal College of Obstetricians and Gynaecologists and a Fellow of the Royal Australian College of Obstetricians and Gynaecologists. I wrote my thesis on the prevention of unwanted pregnancy, in other words, trying to develop a test that would identify the fertile period, whilst a research fellow in the Middlesex Hospital and my major research interests are in the prevention of disease, particularly in the three areas of cervical cancer, post-partum haemorrhage and unwanted pregnancy.

I think that the committee has an exceptionally difficult task and I genuinely laud their efforts and don't pretend that the issue isn't difficult. I wanted to discuss three points in the few minutes I have before questions. The first one is the question of abortion being a yes-no, right-wrong, black and white issue. The second one was whether or not there are - and what are - the medical indications for termination of pregnancy and the third one is trying to put abortion amongst Irishwomen in context from my point of view as a practising clinician interested in women's health.

Every year I ask the medical students in their fourth year what they think about abortion. I ask them as a group and I ask the entire class, giving them three options - abortion should always be available on demand, it should never be available on demand or it should be available in certain circumstances. Over the last ten years the division of responses has roughly been 1 to 2% saying never, 1% saying on demand - or less than 1% - and 97 plus % saying in certain defined circumstances. These circumstances vary according to the individual medical student and I believe that that's the same for the general medical population.

Whether a particular woman or doctor or the public at large would agree with a woman choosing to have a termination of pregnancy depends on a number of factors quite apart from the religious or moral stance of that person or community. I think there are a few people in our community who feel that abortion is always wrong, but I believe that they are actually very much a small minority. Several factors that come into play for a doctor faced with a woman who has an unwanted pregnancy really do, I believe, influence the decision-making process and these are: the gestational age, the specific circumstances of the conception and the condition of the mother and the condition of the foetus. Who in this country cannot tell the difference fundamentally between a newborn baby and a conception of just a few hours which has not yet implanted in the womb? In my view, most doctors and most men and women of reproductive age do not have a profound difficulty with preventing this pregnancy from implanting - witness the very widespread prescription and the use of the post-coital pill and the common use of the intrauterine contraceptive device.

In terms of the specific circumstances, the committee has already heard from a previous expert witness declaring the profound distress of a woman who has been raped. I believe that most members of the medical profession and the public are supportive of early termination of pregnancy in this circumstance. In relation to medical indications of termination of pregnancy, for reasons that are not entirely clear to me, the public debate and legislative and political discussion concerning abortion seems to have concentrated largely on the individual issue of medical indication of termination of pregnancy. There are both maternal and foetal circumstances where termination of pregnancy would be indicated on medical grounds.

Again, I think we have tended to see medical indications as a yes-no, black and white, right or wrong perspective, whereas in truth the risks are relative. Whilst it is absolutely true that there are medical circumstances where termination of pregnancy will profoundly reduce the risk of a woman dying, it is not true to say that a woman will definitely die if she continues with her pregnancy no matter what the condition. It is a question of relative risk. You have already heard of Eisenmenger's and serious aortic stenosis. A woman with Eisenmenger's will not have a 100% risk of dying if she continues with pregnancy, but her chance of so doing will be about 40% if she does and you have already heard reference to resource material for that condition. An early termination of pregnancy in these circumstances will profoundly reduce this risk. Indeed, there are very few, if any, circumstances where pregnancy is not more risky than early termination of pregnancy, but the chance of the mother dying is so small in most circumstances that both doctor and mother would not wish for anything else than continuation of the pregnancy.

In terms of foetal indications of termination of pregnancy, it is perhaps hard for people to understand that a termination of pregnancy should be considered for foetal reasons in certain circumstances. If a foetus has a condition that is not compatible with life and where the mother and doctor consider that continuing with the pregnancy will serve no purpose and that it will be associated with unnecessary physical and psychological suffering, then a termination of pregnancy is indicated, I believe, reasonably. Anencephaly is such a situation. Women with anencephaly in Ireland are unusual compared to the European and North American and Australian circumstance in that they usually do not have the choice of terminating a non-viable pregnancy until that foetus has become viable, such that it can be born alive, then suffer and then die. I believe that benefits nobody. It doesn't benefit the mother, it doesn't benefit the foetus - all it can do is add to the suffering of the mother. I don't mean that every anencephalic pregnancy should be terminated. Several mothers will choose to continue with their pregnancy, to deliver their baby, to hold their baby and to grieve, but other mothers will not choose to do that and in other countries they have that choice.

Also, you have already heard from an expert witness last week about the difficult problem of parents with children who have cystic fibrosis and those same parents who wish to have further children without this condition and I don't wish to repeat that.

The third issue I wanted to mention very briefly is the question of putting abortion in context. The problem with abortion for specific medical conditions or for rape is very rare. You know this, I know it, everybody knows it. Six thousand women or so chose to have a termination of pregnancy annually and they do so, in the great majority of cases, because of social, economic or other reasons. I believe this is the real issue which should occupy most of our time both in this committee and in the wider public forum. I appreciate that it is not within the strict terms of reference for this committee but in the same way that the major management approach to cervical cancer is the recognition and treatment of pre-cancer, so we should very seriously consider preventing the huge number of unwanted pregnancies that occur.

If we are considering what to do about abortion in Irish women, I am presuming that the primary concern pivots around two central actuarial issues of, first, how to reduce the unnecessary high rate and, second, how to improve the care of women who have unwanted pregnancies. There is very good evidence from abroad that in the absence of access to legalised abortion, women will resort to illegal abortion. Illegal abortion is not good for anyone. Illegal abortion is associated with high rates of very genuine morbidity and significant maternal mortality. I appreciate this situation does not prevail in Ireland because Irish women have ready access to abortion services in the UK, albeit without the necessary counselling and post-termination of pregnancy care that they so desperately need and that all their English counterparts receive. So long as the UK continues to provide access to abortion services for Irish women, the likelihood of Irish women resorting to illegal termination of pregnancy is remote and negligible.

Finally, there is good evidence that there is an interdependent relationship between abortion rates and contraception in terms of availability, accessibility, education and perhaps a collective cultural responsibility towards sexuality in teenagers. It is the combination of these factors which will dictate how many women will end up with an unwanted pregnancy. Each country appears to have a different approach to this problem. Many have arrived at their circumstance by deliberating seriously and implementing specific programmes; I am thinking of the Netherlands. In Ireland, we seem, until now, to have dealt with this by crisis management. We haven't planned how to deal with the fact that a lot of our communities' young men and women are having sex and that unless we equip them with the necessary information and means to deal with this situation, we will have a massive burden of unwanted pregnancies and of human suffering and our rate of unwanted pregnancy and abortion will continue to rise. It seems to me that, until now, we have seemed unconcerned about this. One of the reasons, and I think it is a very important reason, is that women with an unwanted pregnancy do not publicise their plight. Rather, quite reasonably, they wish to hide it, forget it and get on with their lives, and who can blame them? However, it is a very real and substantial amount of human suffering and we, the health care providers and the politicians, should rightly be judged in terms of how we deal with this problem.

If we are really serious about the problem of abortion and how to reduce its volume, we should begin to look at the evidence available elsewhere and which strategies are associated with the lowest rates of unwanted pregnancy and abortion. Simply legislating for or against abortion in different circumstances will not alter the abortion rate amongst Irish women. We need to look at the Netherlands and other countries with low rates of abortion and ask ourselves how they arrived at their low rates, and we need to look at Romania and Russia and other countries with high abortion rates and ask how they got it so spectacularly wrong. Otherwise, we will be condemned to continue with similar rates to the UK, at the very least. I thank you for your time.

Chairman: Thank you very much, Professor. I would ask the members to indicate if they want to ask any questions. Deputy O'Keeffe.

Deputy J. O'Keeffe: Thank you, Professor. We had some discussion last week among those who were making submissions as to how exactly we define abortion because it is not defined in the Green Paper which we are considering. How would you define abortion?

Professor Prendiville: I am actually amazed that the committee have not yet defined the term "abortion". Abortion is synonymous with miscarriage when the pregnancy terminates spontaneously without interference, though in the traditional text books the termination of a pregnancy by either spontaneous natural occurrence or by interference is called abortion, and they have traditionally been called the same thing. In other words, the ending of a pregnancy before viability is what an abortion is, and viability has changed over the years. Classically it is divided into first trimester termination of pregnancy, the first third; mid-trimester termination of pregnancy; and thereafter you are talking about viability. Now that viability gestational age has come down from 28 weeks to either 500 grams or 24 weeks in many countries but, by and large, for the very great majority of circumstances, termination of pregnancy, where the pregnancy terminates as a result of interference, is considered in the first trimester. There are very few normal pregnancies that are terminated anywhere after the first trimester, though that does happen.

Deputy J. O'Keeffe: I gather from your evidence that you feel uncomfortable with the present constitutional and legal framework within which we are operating in Ireland. Is my impression correct, and do you have any specific proposals that you would like to leave with us as to how either the constitutional or statutory aspect should be changed?

Professor Prendiville: If I can step back just for a moment and say that I am not at all an expert in legal or political progress. I believe that the way we have managed it so far is quite wrong and I think that if we continue in the way we have that we will be likely to continue to get it wrong. I would leave the methodology and logistics of how to change the status quo to those more expert than I, but I would say that if we continue with our current policy in terms of reproduction for women, it is likely that we will continue to have similar rates of abortion to the UK and to Australia and the US. I think we are unlikely to reach the excessive numbers of eastern Europe and the developing world as more and more of our women become educated, but I believe if we really do wish to reduce the abortion rate in Ireland, we have to look at those countries that have legislated such that not just the availability of contraception but the accessibility of contraception and the education of our young women and men is profoundly increased, and the classic country is the Netherlands, but many northern European countries would adopt a similar philosophy.

I have to say that whether or not abortion is available in Ireland for social reasons is a relatively unimportant issue so long as Irish women can continue to access abortion abroad. What is more important is how we go about reducing the number of women who have an unwanted pregnancy. I think that is the most crucial point that we as a society and this committee need to consider. There is fairly clear evidence that accessibility as well as availability ... everyone knows that the pill is available and that various contraceptive methods are available in Ireland but we have a genuine problem in that many of our young men and women do not use contraception for their first or early sexual experience, and the Netherlands and other northern European countries have managed to educate their very young teenagers such that before they have their first sexual experience, they are prepared and much less likely to have an unwanted pregnancy. As it happens, the Netherlands has a very low rate of abortion. As it happens, they have a very low threshold for doing abortion at a very very early stage, and they have access to early abortion, very wide, very generous access to early abortion. Now that's, if you like, a separate issue and I think the real message from the Netherlands is that they educate their young men and women very early and that they make contraception both available and highly accessible, and I think that is what we should consider.

Deputy J. O'Keeffe: Your comparison of Ireland with the Netherlands is that the Dutch have education - a lot of it at a young age. They have availability and accessibility to contraception, particularly the young people. They have what would be termed a liberal abortion regime and yet they have a lower rate of abortion-----

Professor Prendiville Than anywhere else in Europe or in England, considerably lower. There is a very good paper by - I can't pronounce the names terribly well - Kulczychi, Potts and Rosenfield in The Lancet in '96 that compares abortion rates throughout the world and the use of contraception. I commend it to you. It is called "Abortion and fertility regulation" and I can let you have it. It was in The Lancet in 1996, volume 347, pages 60 and 63 to 68. It reviews that question and the relationship between contraception and abortion availability very carefully. I really think it puts it into perspective. Essentially, I am saying that I believe - and I certainly think it is worth exploring - that education of very young people, accessibility of contraception and a responsibility to sexuality that prevails in northern Europe - and it does not prevail even in England nor in Ireland amongst our teenagers - is the only way we are going to change our society. I think that what we legislate for will actually not make any difference to 99% of the women who have an abortion.

Deputy J. O'Keeffe: We have your evidence on the comparison between Ireland and the Netherlands. Can you paint a picture of the comparison between Ireland and the UK in relation to education and abortion rates generally?

Professor Prendiville: I think that we have very similar abortion rates. I think, like here, the UK has very widespread availability of contraception, but has very very patchy accessibility and sex education and that there are a huge number of poorly educated people in the UK who are not well educated at the appropriate age because most terminated pregnancies happen to teenagers and to young women. Mostly young men and young women in England are relatively uneducated in this regard, whereas their counterparts in northern Europe or in the Netherlands are very much more educated. We are like the British in this regard.

Deputy J. O'Keeffe: Could I just ask one other question, Professor? You are aware of the constitutional complexities here and indeed the legal framework. If there was - and I will not ask you for a one sentence solution - if you were to make one major recommendation, if you had it within your power to implement one recommendation to effect a reduction in the abortion rate in Ireland, what would that recommendation be?

Professor Prendiville: That recommendation would be to adopt a strategy whereby our young women and men were educated and provided with the means to prevent unwanted pregnancy at a very early age.

Deputy J. O'Keeffe: Thank you, Professor.

Chairman: Just one matter arising from Deputy O'Keeffe's questioning, I don't know whether you studied the position in Germany and in the Federal Republic before and since unification.

Professor Prendiville: No, not in that regard.

Chairman: I would be interested to hear and I wonder if you could assist us at all from the literature in that regard.

Professor Prendiville: No, but it would not be hard to access the references and to provide those to you, but the specific circumstances in East and West Germany I am not familiar with.

Chairman: It is just that West Germany had our position of a constitutional ban, though not as rigid a constitutional ban as is here, but had a very definite constitutional limit and appears to have had a much lower abortion rate, but it may be that it was a combination of that constitutional limit and similar type approaches to the approaches you talked about in the Netherlands.

Professor Prendiville: I am sure that is true.

Chairman: That is why I thought it would be interesting to explore because culturally it is that bit closer to us in its tradition-----

Professor Prendiville: Yes.

Chairman: -----though I gather since unification matters have changed in Germany because a more liberal legal arrangement had been introduced as a condition of unification, but it was an experience that I thought might be of assistance to us and I wondered could you help us on it in any way?

Professor Prendiville: Not at this time. I'd have to read up on Germany.

Chairman: I will take Deputy McManus.

Deputy McManus: Thank you very much indeed. First of all, thank you very much Professor Prendiville for coming here this morning. We appreciate very much your attendance here. I have a couple of questions. The first one, maybe if you could just clarify for me this issue of risk to the woman's life and possible risk to a woman's health. Are there circumstances where you feel that terminating a pregnancy would be significant in terms of protecting a woman's health?

Professor Prendiville: Yes, I do because I think that the risk of dying is the extreme result of a particular medical condition and morbidity is the lesser outcome, so there is absolutely no doubt that in the very rare circumstances where a termination of pregnancy is recommended for a maternal indication, that if the mother doesn't die, she is likely to suffer significant morbidity. I am talking now about all of the medical conditions whether they require an indirect or a direct termination of pregnancy. So, yes I do, I think that serious morbidity or health risk is a lesser outcome than mortality. Mortality is easier to measure, but for every mortality there is a lot of serious morbidity. So, yes, I think so.

Deputy McManus: Thank your very much. You have separated out in a sense the sort of medical conditions or issues where, for example, a women with anencephaly that kind of situation, where you feel there is an argument for abortion. Some of the people who came before us in the last few days have made the point that it really does not matter whether it happens here or in England, but the point that was made by some of the doctors was that they felt that there was a difference in the sense that the standards in Britain weren't necessarily always proper and that there were difficulties, for example, in that particular situation with post-mortems or lack of information where maybe an autopsy isn't even held or the information isn't coming back. Is there not an argument that in those circumstances, leaving aside all the others, although I hate the word "social", but you know separating it out on those medical grounds, is there or is there not an argument for providing that kind of service here?

Professor Prendiville: I would have to agree with you. I think that there is a very strong argument for having a termination of pregnancy available in a country for medical indications, maternal or foetal. When I said that I didn't think it mattered quite so much, what I was really trying to say was that for women who are healthy, we are unlikely to see serious morbidity and mortality if they have their termination of pregnancy in the UK. In other words, they won't have to resort to illegal abortion. For women who have genuine medical conditions, and there have been several in the last few years, they have by and large been referred abroad, I think that they are disadvantaged by going to the UK. Of course, the more serious the medical condition, the more likely that the referring doctor will pick an institution in the UK with very excellent health care, but there is no doubt that it would be better, I believe, for that woman to be able to have her termination of pregnancy in Ireland.

Deputy McManus: Could I ask another question? One of the assumptions that has been coming up has been that if you do legislate to provide abortion here, even circumscribed very tightly, that the floodgates open inevitably. I have difficulties with that assumption, particularly when I look to see what has happened in Northern Ireland, where it does appear to me that there is circumscribed in law conditions whereby women can have abortions and it would appear that the floodgates haven't opened, possibly because again people go to Britain. Do you see it as the inevitable outcome if one does provide abortion in certain circumstances, which aren't allowed for at the moment, like anencephaly?

Professor Prendiville: I would say two things. First of all, the floodgates are already open - 6,000 women go and have a termination of pregnancy every year, so the floodgates are already open. Our charge is to shut the floodgates, not to prevent women with unwanted pregnancy having a termination of pregnancy, but to reduce the number who get pregnant. That's our challenge.

Secondly, the great majority of Irish obstetricians and gynaecologists do not wish to perform termination of pregnancy in the so-called social bracket. They just do not wish to do that. With the greatest of respect for colleagues outside the major general hospitals, or indeed maternity hospitals, the number of institutions that would be likely to be equipped to carry out termination of pregnancy for sick mothers is fairly limited. Therefore, the floodgates, I think, are unlikely to open if this committee legislates or advocates legislating for specific medical conditions. You cannot fake an anencephalic, you don't fake an Eisenmenger's. So I think it's very, very unlikely and I do not see my specialty taking on social abortion at this time or in the foreseeable future.

Deputy McManus: I have two final questions which I will ask together. First, I am supportive of the view you hold in relation to preventing crisis pregnancies and I think we have failed totally to face up to that. Education is the key. I wonder if you feel that, for example, a simple measure like contraceptives being available on the GMS, the medical card, is the kind of practical approach we should adopt. Second, you have written about possible developments in relation to abortion where, for example, in the future it may be - it seems to be happening already - that a woman would take a pill and that that may change the doctor's approach to the issue in the sense that it is - in your own words and I hope I am not misquoting you - as much about aesthetics as it is about ethics.

Professor Prendiville: They're somebody else's words which I quoted but they do reflect a particular dilemma - not dilemma, they reflect a very genuine entity. You are asking two questions. The first one in relation to early termination, the second one related to early termination versus late. I referred to it earlier and I really do feel that the great majority of people, not just of reproductive age but specifically of reproductive age, do not have a huge ethical problem with preventing the implantation of a very early conception, when it is a few cells and not formed into a foetus, obviously incapable of independent life and not recognised, not hominised, not ensouled, not human.

I think that the very great majority of people do not have a particular problem with preventing that pregnancy becoming a viable human being. That is witnessed by the widespread, one of the highest rates of post-coital contraception in Europe we have. The widespread use of post-coital contraception and the lesser but definite use of the IUCD suggest to me that doctors and the general public don't have a profound ethical problem with that situation. But the great majority of people have a serious ethical problem with termination of pregnancy at later gestational ages. So I think that really does reflect the fact that the ethics of this situation are not black and white. They are very grey.

To answer your second question, I'm quite sure that in the future we may be able to avoid the experience of the UK and the horrendous, awful circumstance of having to evacuate a uterus in a healthy woman with a healthy pregnancy where the pregnancy is identifiable as a foetus and recognisable, etc. I think that in the very near future it is likely, already it's likely, that it will be possible to terminate pregnancy before it is a serious ethical problem for the majority of people. That demands widespread education about the recognition of ovulation, of pregnancy and the accessibility to a facility that would allow people to prevent them becoming pregnant, so to speak, when they have already had intercourse in an unprotected way. I personally believe that that's the way forward and we may be able to completely miss the awful circumstance of termination of pregnancy that's happened throughout the world. I think we should put some money into researching and understanding very, very, very early recognition of conception at this time.

Senator O'Donovan: I welcome the Professor. I have a couple of queries. Some of the points I wished to make have already been raised. You mention lack of education, maybe in our schools or parenting, as being possibly a major factor in the large number of unwanted pregnancies. Having regard to the fact that our young population is seen, not alone in Europe but throughout the world, as being one of the most educated, how can you align this ignorance on one aspect of our lifestyle? Is it a taboo, is there a stigma attached because we are primarily a Catholic country or have you any views to offer on that? In other words, it does not make sense when somebody says that. I have teenage children and in a village not too far from where I live in a very remote part of rural Ireland there are contraceptives available in both the ladies and gents toilets of local pubs. I believe that in rural Ireland the morning after pill is quite freely available. Having regard to all that, it puzzles me that there are nearly 6,000 women at a later stage in pregnancy going abroad to have terminations. It doesn't add up to me, as a lay person.

Professor Prendiville: I can understand the difficulty in saying that we need education. We are perceived and we perceive ourselves to be a very educated population. I think in many ways we are. But I don't think education in terms of ability to earn money or education in terms of appreciation of literature or music or politics translates into or confers upon us sexual education.

I believe that we don't have the same level of education in relation to sexuality at the particularly crucial time when men and women are at risk of having unprotected intercourse. There are very few people who are over 30 who do not understand how to avoid getting pregnant and, indeed, how to access the means to prevent unwanted pregnancy. But there is a huge population of women in Dublin and in Kerry, Galway and Donegal who (a) don't understand how to access contraception and (b) actually don't have a clear understanding of the risk of pregnancy. So I think we are educated in many areas of life but I don't think we are particularly educated as a population at that time in our development sexually.

Senator O'Donovan: I wish to follow up a question Deputy O'Keeffe raised on the definition of abortion. I'm a little confused on this. You are probably the tenth medical expert to come before the committee. At least two and possibly three were slow to align the terminology of abortion with termination. I got the impression from at least two, if not three, of the expert witnesses, without naming them, that they felt in crisis situations where there was maybe a serious heart condition with the mother, where the ectopic pregnancy occurred and a couple of other conditions such as cancer of the cervix or a severe medical condition had developed, that the spontaneous abortion you mentioned-----

Professor Prendiville: Induced.

Senator O'Donovan: Whatever. Doctors differ and patients die, so to speak. I have a difficulty in trying to ascertain if the other experts are on a wrong vein if they say: "Such instances are not abortion per se". It's involuntary termination or whatever and it's acceptable. I think it's acceptable to Catholic Church teaching in certain instances.

It would be helpful to me, as a member of this committee, if there was a definitive, clear decision on what is or isn't abortion. Some of the experts said that abortion in any circumstances whatsoever, either induced or spontaneous, is a type of abortion. Others were inclined to say that's not really abortion. Abortion is a sort of dirty word. Where would you stand on that? I'm not trying to trap you into criticising what others said.

Professor Prendiville: I'll try to avoid being trapped. I understand the difficulty. I think its a reasonable difficulty. If you look in the textbooks of medicine and obstetrics and gynaecology, abortion is defined as the ... when a pregnancy ends before viability. Now, abortion can be spontaneous or it can be induced. It is very reasonable for colleagues to wish not to use the term "abortion" if they perceive that that may result in them not being able to look after women at risk of dying in specific circumstances. I can understand too the genuine ambition of colleagues from a particular philosophical point of view who wish to facilitate the treatment of women with cancer by calling that circumstance an indirect abortion, whereby you're treating the condition as opposed to terminating the pregnancy.

If you look at the classical textbooks, an abortion is an abortion and the reason it occurs is variable. In other words, it is the ending of a pregnancy whether that ending occurs because of nature, because of the doctor or because they are treating a condition or not. Now, there is a move in nomenclature circles to change the word "abortion" to "miscarriage" when the pregnancy aborts spontaneously and to reserve the term "abortion" for the circumstance when the pregnancy is terminated by medical intervention rather than natural. That's a reasonable distinction because a lot of people do not like to be told they've just had an abortion when they've spontaneously miscarried. But, in the classical traditional textbooks an abortion is when a pregnancy terminates before viability.

Senator O'Donovan: Now, this is a view that I have gathered from listening to political people of different persuasions over the last two years since this committee was formed. There seem to be three different views coming forward. Some of my colleagues may or may not agree. One is that there seems to be a demand, echoed by some political people, for an absolute constitutional ban - absolute, full-stop. The other would be a constitutional change incorporating certain clear parameters where this may be allowed or not, as opposed to sort of open-ended abortion on demand. The third would be mere legislation.

I personally feel that, having regard to the 1937 Constitution, to the amendment and to the X and C cases, it would be difficult to ignore the Constitution whichever road we take. I am just wondering have you a particular view or do you feel - you may have answered this already and I don't want to go over it - that legislation in itself will be adequate. If so, is it possible that the Medical Council or the association of gynaecologists and obstetricians can set out clear parameters of exceptional cases where this would be allowed?

Professor Prendiville: I find that a very difficult question to answer because I'm not an expert on the Constitution or on the law. But I believe, to answer one aspect of your question, that the Institute of Obstetrics and Gynaecology would be likely to be able to circumscribe specific medical indications, be they maternal or foetal, where termination of pregnancy is justified on medical grounds. I believe that the great majority of the population wish to see that available. I don't believe that ... I'm sorry, I don't know whether the great majority, or whether any majority of the population, wish to see termination of pregnancy here for other reasons. I think that is unlikely, personally, at this point in time for a number of reasons, but I think that the majority of both gynaecologists, general practitioners and the general public would like to see women with genuine medical indications provided for in this country. I think that the Institute of Obstetricians and Gynaecologists, which would be the appropriate body and would be able to frame such circumstancs.

I mean, the other thing is that a paediatrician faced with a very difficult decision about when to turn off resuscitative equipment with a very sick or non-viable child doesn't have the decision decided at a referendum, quite rightly because circumstances change so profoundly and it is not fair to ask a doctor to have to accommodate that. I think it's very similar with abortion for medical indications ... that if you allow the profession, once it declares itself, to work in the best and most caring way for its patients, it's likely to run a sensible course in changing times. Cardiac conditions were not a major problem 30 years ago, very few of them survived to adulthood. Now, cardiac condition patients do. Some of these problems are new and the times will change, conditions will change. To proscribe it I think will cause difficulties, certainly in terms of a referendum. I think a referendum is the wrong way to go, but I have a very innocent view of constitutional and legal matters. I'm not an expert in that regard and don't wish to be or pretend to be.

Chairman: We are nearly at full-time. I call Senator Dardis.

Senator Dardis: You've made the point very forcibly to Senator O'Donovan and also, I think, to Deputy O'Keeffe regarding you're lack of expertise in the legal area and I accept that.

Professor Prendiville: Thank you.

Senator Dardis: I don't wish to ask you to express a legal opinion. Nevertheless, do you think it is possible to define circumstances within a constitutional framework? I mean, surely we are asking for something that's too complicated in that situation.

Professor Prendiville: I think you are correct in that assumption. My belief is that it is too difficult to proscribe constitutionally the various factors - gestational age, degree of sickness, relative risk of dying, degree of normality of the foetus, likelihood of termination to cause problems etc. It is very, very difficult to include that in a succinct and understandable framework that the general public can understand.

Senator Dardis: Well then that leads to the next question and the next question is ... you spoke about the 97% of the students who would favour termination or abortion in defined circumstances. If the circumstances are very clearly defined, do you think that that would preclude the possibility of social abortion, so to speak? In other words, is it possible to achieve that objective?

Professor Prendiville: Yes, I do believe it is possible to achieve that and I think Northern Ireland has done that. I think that, unless the nature of the profession of obstetrics and gynaecology changes radically, it is very unlikely that social termination of pregnancy would be accommodated within the specialty of obstetrics and gynaecology. So, I personally feel that it is possible to do that and that the Institute of Obstetrics and Gynaecology would be unlikely to betray that trust were it endowed upon them. That's my own belief.

Senator Dardis: There was a view expressed to us last week as to where abortion should be available in circumstances where it would be allowed or where it would be required. The view was very definitely that it should be restricted, let's say, to the teaching hospitals or to major centres. Do you have a view with regard to that?

Professor Prendiville: I personally would not like to see it restricted to particular hospitals because I think individual hospitals have different ethical frameworks and some of our hospitals are controlled by boards of lay people rather than medical people. I think it is fair to say that termination of pregnancy in the rare circumstance where medical indications prevail would need to be carried out in a hospital of sufficient size to have the expertise and resource to look after that woman and there are not many of those. For a woman who is very sick, there are not many.

Senator Dardis: I have a final question which is unrelated. You spoke earlier on about the first experience ... the younger people .. that that tended to be the unprotected sex where you had the possibility of the unwanted pregnancy. But, I noticed that in the Adelaide Society's submission they talk about many Irish women have termination of pregnancy at a later gestational age than their British counterparts. Perhaps you could reconcile that for me.

Professor Prendiville: Yes, indeed. I think that they do so because they recognise pregnancy later and because they get to counselling services, if they go to them, and get to termination facilities later than their counterparts do in the UK so I don't think they are irreconcilable. Just to add to your previous point, I think you'll find it as difficult to find a tertiary level referral hospital who wishes to take on the responsibility as you will to have to one to curtail it.

Senator Dardis: One final short question. There is a lot of talk about the advances in medical science, advances in technology. To what extent can we anticipate that diagnostic technology is advancing at a rate that will allow us to identify some of these extreme situations at a very early stage so that the intervention can be at an early stage?

Professor Prendiville: I really don't feel I'm sufficiently expert to give you a concise answer to that. I think that would need a prepared response and I think the person to answer that best would probably be Sean Daly who has done a fellowship in materno-fetal foetal medicine. I am sorry to pass the buck and Sean, I'm sorry, but that's what I believe.

Chairman: We've heard from him already in fact.

Deputy J. O'Keeffe: Missed the boat.

Senator O'Meara: Thank you also, Professor Prendiville, for coming to speak to us today. In particular I'm interested in your remarks about the Netherlands experience and the challenge to us which I think as legislators we must take up to effectively, as you put it yourself, shut the floodgates which are already open from this country in the direction of Britain, but not in a legal sense necessarily, rather in terms of how we deal with the issues of sexuality, unwanted pregnancy and so on. Before I do that, I just want to ask you something specific in relation to what you said earlier about very early termination of pregnancies. I wasn't clear whether you were referring to the availability of the morning-after pill or whether there were other scientific and medical advances which we might not necessarily be familiar with as lay people.

Professor Prendiville: No, I am referring to post-coital contraception, the use of the intra-uterine contraceptive device but I am also referring to the rapidly changing area of understanding in relation to very early pregnancy, such that in the UK many women will choose to have termination of pregnancy by taking a tablet. That's by and large not available to Irish women. At this point in time, it's not quite as successful in very, very early pregnancy but I believe that the time is coming and I believe it is worth investing in research in this area, to develop technologies and pharmacologies that will be able to prevent an established pregnancy. I do believe that even at this point in time, if there were widespread availability and accessibility to the recognition of pre-implantation pregnancy that that would be ethically much more acceptable to many people than termination of pregnancy at eight, ten and 12 weeks is.

Senator O'Meara: You are effectively talking about the morning-after pill - are you? I just want to be clear. Are you talking about what I would understand to be the morning-after pill?

Professor Prendiville: I am talking about the morning-after pill but I'm also talking about other things. There is a window of time between post-coital contraception - many people prefer not to use the term "the morning-after pill" because it suggests that it only works the morning after whereas it works for about 72 hours and the IUCD as a pre-implantation device for up to about five to seven days. There is a window thereafter until pregnancy is eight, nine weeks and it's only after that that termination of pregnancy is actually successful in a reasonable proportion of cases and I believe that window of time, certainly until the expected menstruation and in the few days and perhaps week after, that that is the area that we should concentrate on, that may allow us to prevent implanted pregnancies in the future.

At this point in time, I think that ethically many people believe that post-coital contraception, be it the 72-hour pill or be it the five, six day IUCD is very ethically acceptable in a crisis pregnancy and that a lot of people would not find termination of pregnancy later acceptable. So I think that to mount a campaign of recognising pregnancy the minute it's happened and facilitating prevention of implantation would be far more ethically acceptable to our population at this time than what happens at the moment. Infinitely more acceptable to both sides of this argument, the pro-life movement and the pro-choice movement, is the idea of preventing pregnancies and whilst there may be different strategies which both sides advocate, they have a common ambition and perhaps that is what we need to-----

Senator O'Meara: Yes, which brings me to the second question which is the common area, I think, among all of us which is that we need to look more carefully at why we have such a high rate of unwanted pregnancy and why we have such a high rate of abortion and in the Mahon, Conlon and Dillon study, I don't know if you are familiar with it-----

Professor Prendiville: Yes I am.

Senator O'Meara: I have referred to it before. There are issues there which you have referred to yourself, for instance, the fact that so many women travel to England without any counselling, that so many go for reasons of secrecy which you've referred to. I certainly find it worrying, to say the least, that women who choose to have an abortion for reasons of secrecy only and to block out or deny, shall we say, the other issues that come into play and what that says about our culture here in this country, particularly about our attitude to sexuality. We still have a long way to go, I think, in relation to dealing with issues of sexuality. The fact that the relationships and sexuality programme is only now starting in schools leads to - it will be a time before we can study whether there is a positive effect in relation to reducing the number of pregnancies, particularly teenage pregnancies, but it also raises the question as to whether it would be possible for say the legislator or a Minister for Health, for instance, to effectively launch what it appears to me to be what you're suggesting is a proactive campaign of sexuality education, of contraception education, of much broader accessibility to contraception, particularly to young people, probably you're looking at 16 to 18 year olds and younger-----

Professor Prendiville: And younger.

Senator O'Meara: -----considering that some of our very high profile legal cases have involved teenage girls, you know, and we know of course as members of the public and as legislators and public representatives, that there is a major issue around teenage sexuality. To actually move towards that kind of campaign would suggest that we need to be looking at a proactive campaign of sexuality education in schools, in the community, advertisements and television and all that and that you actually would need to move into that space if you are genuinely looking at reducing the number of pregnancies and reducing the number of abortions in particular.

Professor Prendiville: I agree. I think somebody needs to be funded to do some research on how exactly the Netherlands have achieved it and to develop some pilot programmes here and to determine if they work and, indeed, any other strategies that any other lobby group wish to put forward should also be evaluated in the Irish context and evaluated, urgently.

Senator O'Meara: Thank you for that.

Deputy M. McGennis: To follow on actually directly from the last question and the last point that was made, I would immediately embark upon the kind of campaign that you're talking about of relationships and sexuality or sex education and more freely available contraception if I felt that that would in fact reduce the numbers of unwanted pregnancies or crisis pregnancies, but I think maybe what we are missing out on is, and maybe that your suggestion that funding be made available for research on the Netherlands experience might actually reveal something else which we haven't discussed so far and which we haven't discussed an awful lot during the hearings - that is the relationship between parents and their sons and daughters. I have no doubt that that is an influencing factor.

I think maybe the degree of openness between a son and daughter and mother and father has a lot to do with whether you see that daughter ending up in a situation of a crisis pregnancy. In tandem with what you're talking about, because if you were to presume, as I would have, that the UK must have reasonably easily accessible contraceptives, has had some sort of sex education programme in place for many years, then they have achieved little or nothing. I think our own studies might indicate that you are finding the instances ... I mean you would see them at your clinic and we would see them at our clinics ... you're finding the instances of crisis pregnancies or, if you like, what would be termed unmarried mothers are cropping up almost always in particular in socio-economic groupings as well. I think that it's not just simple availability of contraceptives and good sex education in schools, it's also to do with the need to, in certain circumstances, educate parents. It appears that where young people have ambitions for themselves you find much less instances of crisis pregnancies or at least maybe those pregnancies being carried through to term. If the young people themselves, particularly young women, haven't a sense of their own worth or ambitions for the future then you're seeing, I think, greater instances of unplanned or crisis pregnancies. I think maybe what you're suggesting is spot on, but I think maybe we're missing a vital component to getting, reducing the numbers of crisis pregnancies.

Professor Prendiville: I'll be brief in my response. I think that it's true that there may be a difference between those women with an unwanted pregnancy who choose or are able or are organised whereby they have a termination of pregnancy, but I don't think that there's a social or economic protection from unwanted pregnancy. It may be that certain categories of women with an unwanted pregnancy in difficult circumstances do not or cannot or are unable culturally, economically or for whatever other reason to choose to have a termination of pregnancy. There are other groups who decide and are organised and do have a termination of pregnancy but I think unwanted pregnancy happens across the board socially and economically, though the outcome may be different.

I think you're absolutely right and I agree with you, and I never pretended otherwise, that I believe the answer to unwanted pregnancy is a combination of interventions. My understanding from the Netherlands experience is that it is an interdependent, multi-factorial approach whereby it's availability of contraception, it's accessibility of contraception, it's comprehensive sex education and life education and it is also a supportive society whether that's within or without the family in terms of educating young people and preparing them for their first sexual experience. I agree that it's a multi-factorial phenomenon and I don't feel that it is necessarily that copying the Netherlands experience is the answer because we live in a different world and we have different ... it may not be possible to provide the kind of education that is truly protective in our circumstances. I believe that what we should do is define a number of strategies and research them by randomised control trials or by intervening in different areas in different ways so that we can rapidly discover which is the best answer for our country at this time but we need to do so quickly.

Senator O'Dowd: There's just one point I want to clarify. It's just the options which in the future will be open to mothers or expectant mothers. You were saying you have the morning after pill. I'm just trying to get what is the next timeframe that you're talking about, an absolute timeframe, theoretically, that they do have the option of taking a pill as opposed to having a physical abortion?

Professor Prendiville: At this time it's the post-coital contraception, which is 72 hours, and the inter-uterine device, which prevents implantation up to five/seven days. Thereafter, there is not as yet a well researched available pharmacological or other intervention that is successful in the first few weeks of gestation post-implantation.

Senator O'Dowd: In terms of the timespan where you think that in theory one could theoretically work?

Professor Prendiville: I don't wish to speculate but I believe-----

Senator O'Dowd: When then does the actual implantation finally take place in medical terms?

Professor Prendiville: A week to ten days after conception. I think that that is the time that it is ethically acceptable to an awful lot of people to intervene. Whether that will change in the future or not I'm afraid is entirely speculative.

Senator O'Dowd: Fair enough. Thank you.

Chairman: Professor Prendiville, I'd like to thank you for coming to us this morning and assisting us as much as you have and for making what is no doubt your very valuable time available and your experience in these matters. I certainly derived great benefit from what you told us. Thank you very much.

Professor Prendiville: Thank you very much.

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