Chairman: We have a quorum and are in public session.

Before commencing today's hearings there is one matter which I wish to deal with. A verbatim transcript of our hearings of 17 May 2000 with Dr. T. K Whitaker and the De Borda Institute has been produced. Is it agreed that we print and publish this verbatim transcript as provided for under Standing Orders? Agreed.

Deputy J.O'Keeffe: Do we have to do that for every report - the report of each day's hearings?

Chairman: We are continuing in public session and I would like to welcome the following representatives of Psychologists for Freedom of Information, Dr. Geraldine Moane, department of psychology, University College Dublin, and Professor Hannah McGee, department of health services research, Royal College of Surgeons, to this meeting of the Joint Committee on the Constitution in connection with consideration of the abortion issue. We have received your submission, which has been circulated to Members. We intend to table it before the Houses at a subsequent meeting.

The format of this meeting is that one or both of you may make a brief opening statement elaborating on your submission 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.

Just one matter. I think you made a submission to the Department of Health and Children when the Green Paper was being prepared. Do you have a copy of that submission? Could you hand it in to us?

Dr. G. Moane: Certainly, yes.

Chairman: The submission you prepared that we circulated is the submission that was prepared for our committee. Is that the position?

Dr. Moane: Yes.

Chairman: I wonder would you like to elaborate on it.

Dr. Moane: Right. First of all to briefly say that the Psychologists for Freedom of Information is a group of research psychologists and psychologists in practice and we formed around the issue of information, believing that informed decisions are always better. We are also committed to ensuring that best practice applies in counselling and decision making about abortion. Today, Professor McGee will discuss some of the research literature on suicide and pregnancy and will then on go to look at clinical aspects of suicide and decision making in relation to suicide and then some other points, time permitting, arising from the submission.

Professor H. McGee: My area of expertise is in the evaluation and conduct of research on social and psychological factors in health, illness and health care settings and it is in that context that I am here today as part of Psychologists for Freedom of Information. I want to elaborate on some of the evidence the committee has heard to date. We have had the opportunity to look at previous representations so, in the short time we have, I want to further some of the evidence you've heard in relation to suicide in pregnancy.

You have heard mainly about completed suicide during pregnancy but you haven't heard, to our knowledge, about attempts of suicide during pregnancy. Our evidence would concur with the general thrust of the findings that have been presented to you that completed suicide during pregnancy is significantly reduced over and above levels in non-pregnant women of similar ages. However, the protective factor may not be as powerful as the one in 20 you've heard from the Appleby study in the early 1990s in the UK. This was based on death certification. A more recent and detailed analysis in the US in 1999 by Marsoc - we have copies if people are interested - where they were able to have completed autopsy or forensic examination in all cases shows that the risk of suicide in pregnant versus non-pregnant women reduces by about a third. So pregnant women have about a one in three chance of non-pregnant women of similar ages of committing suicide. Importantly, however, although the percentages in all of these studies are low, they represent real individuals. In the New York study, there were six women in four years and in the UK, there were 14 women in 12 years. This is more than one completed suicide per year in both systems where abortion is widely available.

With regard to attempted suicide during pregnancy, there were a number of international studies. There is, for example, a nine year study in Hungary of all persons admitted for self-poisoning to a World Health Organisation collaborating centre there with expertise on self-poisoning. They found in almost 23,000 cases of poisoning by women of childbearing age that 559 of these were pregnant at the time. That is 2.4% but it is 559 women in a nine year period. Most of those women - 61% - had attempted suicide in the first two months of their pregnancy, at the time, they also concluded, where there was an early recognition of an unwanted pregnancy.

A second study looking quite differently at injuries requiring hospitalisation in women of childbearing years in the state of Maryland in the US over a 12 year period by Greenblatt et al. in '97 showed that poisoning was the most common cause of hospitalised injury for pregnant women and that 16.9% of hospitalisations in those 12 years, in other words 369 hospitalisations, were for poisoning in pregnant women. That's an average of 30 attempted suicides by poisoning per year by pregnant women in one US state.

There is a small study in the UK, which may be closer to home, of a five partner general practice in Wales. They looked at their records for women aged 15 to 34 in 1994 and found that 12% of those women had GP records of terminations and 3.5% had records of overdoses and, if you combine them, 1.1% or 15 women in one practice had evidence of both. Most of those women were under the age of 24. There was a significant association between the likelihood of overdose and the likelihood of termination but, with a small number, it is difficult to say what the order was. If anything, the evidence suggested that the overdoses predated the terminations. For us, this combined evidence on completed and attempted suicide in different countries indicates that there are many real life settings, however small they may be in epidemiological terms, in which health and social service professionals have to work to support individual women who are at risk of attempting or completing suicide. In the Irish setting, as has been confirmed to you by the masters of the major maternity hospitals, women and adolescent girls in crisis pregnancies do not currently consult with obstetricians and gynaecologists in these centres to make choices which include termination. There is unlikely, therefore, to be evidence from these sources of suicide risk or loss of life if it usually occurs in early pregnancy.

Suicide or attempted suicide statistics are not routinely collated by pregnancy status so we have no evidence from which to assume that these events do not happen in this country. We have every indication that such events will be presented to individual professionals in the future. The X and C cases are evidence of this in the past. The argument that such events are rare has no bearing on the responsibility of the State to manage them, rare or otherwise. It would be our contention that the State should legislate to support and protect professionals in doing their work in this particular area. I'll hand over to Dr. Moane who will talk about the assessment of suicide and suicide risk.

Dr. Moane: I want to move to the clinical level and deal with a situation where you actually have an individual case who is presenting. In the course of their work, clinical psychologists routinely deal with patients who are suicidal and those settings include psychiatric, community, prison and private practice contacts. They are trained in assessment, decision making and intervention in suicide and the training involves a three year professional training. There are well developed assessment instruments and guidelines for suicide assessment and intervention which were recently published in the Harvard Medical School Guides to Suicide Assessment and Intervention. Furthermore, they would be involved in decision making and one of those decisions would be whether to admit a patient to hospital and, if the patient does not wish to be admitted, whether to be involved in committing a patient and then, obviously, discharge is another area of decisions making.

Decision making is first based on knowledge of the research literature related to risk factors, second, on objective assessment using well established measures and third, on clinical interview with the patient and related parties. Risk factors would include race, ethnicity, poverty, age - demographic factors where you can say, for example, that a young person is more at risk than an older person. Child sex abuse is a high risk factor so its presence would be taken on board. Other factors which emerge in the literature are a positive HIV status, homelessness, family history of suicide, stressors in the family, alcohol and drug abuse history. So if you have a particular case, for example, a teenager with a child abuse history, that would also be higher risk than somebody in her twenties who did not have that history. You take on board these risk factors. You then do an assessment using standardised instruments which would assess depression, anxiety, coping skills and various other psychological areas and also suicide-specific assessment such as suicide ideation using checklists and rating scales which would give you a sense of where a person's condition lies in relation to the norms available for the scale.

The clinical interview would be based on interview with the patient looking at, for example, previous suicide attempts, recent changes in alcohol or drug use, high risk behaviour, taking risks; suicidal ideation - how often the person has thought about it, how frequently, how much, how intensely, how much elaboration; and self-harming behaviour such as cutting, hair pulling, scratching - various indicators that this is not just a mental state of depression or disorder but actually one which is seriously presenting a possibility of actual suicide.

The actual suicidal intention, as in the belief that this person may in fact commit suicide if there is not an immediate intervention, would be assessed by actually examining the likelihood in terms of method, for example. Has the person identified a method, thought about it and obtained the means? The methods include shooting and hanging which are obviously well known but not that common in women, overdoses, jumping from a height, drowning, poisoning, self-asphyxiation - these are the kind of methods which, if a patient presenting said she had actually thought about and was planning out a particular example, would be a seriously high risk.

Further evidence of intention would be withdrawal. People who are serious about committing suicide will isolate themselves, withdraw and hide the evidence they are about to do it because part of what they want is to actually succeed in the act. Isolation, withdrawal, covering up and other efforts to make sure they are not caught or found out or that somebody does not intervene beforehand would be another very high risk indicator in a clinical interview. Giving away possessions would be another indicator of serious intent.

On the basis of the clinical interview information, a clinician would form a judgment that a case was very high risk and required immediate attention, either hospitalisation or 24 hour monitoring, without which there would be a serious likelihood of attempted or completed suicide. Intervention would occur in lower risk situations, for example a suicide contract, where other forms of therapy and counselling are designed to reduce the actual immediate state.

My point is that there are clearly established procedures for assessing the risk of suicide and for making decisions on foot of that which are carried out and implemented in practice on a regular basis which lead to decisions which involve the Mental Health Act in cases of committal. In the instance of abortion, we propose that it would be possible to make a judgment about the risk to life posed by the threat of suicide and to make a decision based on that judgment. These are two major areas of presentation.

Deputy McManus: I thank the delegation for their presentation. We very much appreciate it. It is an area in which there has not been a huge amount of clarity in terms of the issue of suicide so far. I think it's probably true to say that, because of the lack of research in this country and the fact that the research to which you alluded refers to different systems where there is abortion, it's probably hard to be absolutely definitive about the extent of the problem. Would that be fair?

Professor McGee: Yes, absolutely.

Deputy McManus: But you are saying clearly that the issue of suicide among pregnant women is not something that we can discount?

Professor McGee: Yes, I think our point is that epidemiologically, even if we take the parallel with countries where the percentages may be small but the numbers are real cases, that real health professionals are going to have to manage.

Deputy McManus: Dr. Whitaker made the point that, while he accepted that was the case, he believed that in cases of rape and incest, the proportion would probably be higher because of how the pregnancy came about. I think you mentioned child abuse as being a factor in suicide.

Dr. Moane: Child sex abuse is a high risk factor, in other words, there are high rates of suicide among patients who have a history of child sex abuse compared with patients who don't. That would be a recurring theme in the clinical literature of child sex abuse as a risk factor. Then there are also studies .... a couple that I found of college students, for example - Stepacauph 98, Bryant 97, Petrak 99 - all looking at rape victims, which is another area, where, for example, a survey of 393 college students showed that one in four of rape victims reported suicidal acts in the previous year. That's quite an alarming figure. Suicidal acts obviously aren't completed suicides but it certainly shows rape as trauma and a suicide issue in relation to rape and also child sex abuse. The research is there.

Deputy McManus: In relation to the one option that we can pursue which is the question of legislating in accordance with the current constitutional position, including the X case, again Dr. Whitaker suggested that in relation to the issue of suicide, the best way was to provide the kind of safeguards that wouldn't be abused as an option of two psychiatrists giving an opinion on a particular individual. Do you think that's a reasonable approach?

Professor McGee: I think the psychiatrist is the head of a clinical team, from which there is the multi-disciplinary perspective, including social work and psychology, for example. The psychiatrist representing the views of a clinical team... I think we would be happy with the notion of a collaboration by a second independent psychiatrist. I think our view would be that we have to trust the people who make these decisions already in the case of the Mental Health Act. Clearly it's a very difficult decision to make, but it's one where this State is willing to withdraw the freedom of its individual citizens on the basis of their own safety, in the case of the Mental Health Act, in terms of involuntary committal. We already have that system and we trust the professionals to take this very serious responsibility. I think our view would be that we would be happy with Dr. Whitaker's suggestion that this be made and collaborated by an independent grouping.

Dr. Moane: Yes, and that the role of the psychologist there would be according to the assessment. A particular expertise of psychologists is the use of assessment instruments and they would then inform the decision perhaps with their assessment.

Deputy McManus: One option is to simply do nothing, to allow the status quo to prevail and the courts ultimately would make decisions where there are difficulties. I have to say I have a concern with that because I think it's leaving it up to women in very distressed states very often to go to court. Do you think it would have a bearing on the psychological health of somebody in a crisis pregnancy to have to go to court for whatever reason?

Dr. Moane: Absolutely, there could be no doubt about that. An example of that would be the new research on rape and the impact of a rape victim having to be present in a court case. That is an area that's well researched where it's quite clear that the necessity to do a court presentation adds to trauma. So drawing from that example you could assume certainly even more so an instance of crisis pregnancy in a suicidal state would find that extremely traumatic.

Professor McGee: We would also like to add that I think there were two sets of people in that situation. The other set were the professionals. I think it's unfair on professionals to have to act in a vacuum. We would be concerned, since we represent psychologists for freedom of information. For example, Dr. Keane, Master, National Maternity Hospitals, in his evidence on 3 May, made some comments which were unclear, which certainly suggested that there was a reticence about presenting information to women where there was ultra sound about abnormalities inconsistent with life outside the womb. I think it's very regrettable if people feel that they're unable in the current climate to present the range of information that's desirable in a democratic health system about all of the options, even if they're not available in this State. We would be equivalently concerned about the role of health professionals being protected in the conduct of their day to day duties in this area.

Dr. Moane: - and legislation enabling them to provide best care in any situation.

Deputy J. O'Keeffe: I thank the delegation for coming. Their evidence is fascinating. The statistics are very compelling but I'm trying to stand back from it in looking at the suicide situation. Do I get the impression correctly that your evidence is somewhat different to the earlier evidence we had in relation to suicide? If I can first talk about the overall picture. It seemed to me from the earlier evidence we had in relation to suicides that the broad thrust was that essentially because of pregnancy itself, this leads to a lower risk of suicide. Do you accept that is the situation?

Professor McGee: We accept that is the case. I suppose the debate is about how low the risk is. As I said, the paper we can enter in today was published last year in the US looking at the lower risk of suicide. The risk is reduced by one-third, it is not as low as the data from England and Wales, published in 1991, which suggested that the risks were one in 20. Our major point is not to have a debate about how ..... I think we all accept the risk appears to be lower .... the issue is not about how low it is. Our point would be there is still a risk. In every clinical situation where you're sitting in front of a patient, it doesn't matter if this is an extremely rare condition, one in a million, in a medical legal since, you have to be act in the best interest of that patient. It doesn't matter how rare the person is.

Deputy J. O'Keeffe: You accept it's low but it's there?

Professor McGee: It's there.

Deputy J. O'Keeffe: Do you reckon we have to confront the fact, despite the fact it's rare?

Professor McGee: We have to enable professionals to act.

Deputy J. O'Keeffe: On that question, do we have any statistics in Ireland - unfortunately, we have a high rate of suicide, an increasing rate - from recent years as to how many suicides relate to pregnant women?

Professor McGee: No, not to my knowledge. In the published statistics the breakdowns are quite broad. They're in terms of gender, age and socio-economic status.

Deputy J. O'Keeffe: Mostly young men?

Professor McGee: Mostly young men. There is also an increase in suicides among people working in more isolated settings. So young men and older men at the two ends of the spectrum are the highest. We don't have a breakdown by disease or by pregnancy status.

Deputy J. O'Keeffe: Or whether there are any or how many pregnant women is unknown?

Professor McGee: It is unknown.

Deputy J. O'Keeffe: We should have better statistics in that regard.

Professor McGee: It's also unknown how many attempted suicides through poisoning or otherwise would present themselves in hospital set-ups.

Deputy J. O'Keeffe: I had a different impression before you spoke about the ability to have an accurate clinical assessment of the risk. I did get the impression from earlier evidence that it was, if not impossible, very, very difficult to be accurate in that. You would take the view that it is possible to give a reasonably accurate assessment?

Dr. Moane: What they were saying is that it's impossible to predict with accuracy whether the person will complete a suicide.

Dr. Moane: Yes. What they were saying is that it's impossible to predict with accuracy where the person will complete a suicide; in other words you predict the death, to be morbid about it. That actually is impossible because there are so many issues involved in whether a risk of suicide will result in a completed suicide.

Deputy J. O'Keeffe: So you accept that starting point?

Dr. Moane: Yes. You would not, with a degree of certainty people wouldn't be willing to make that prediction, that this will definitely happen. What they have to do, therefore, is make decisions based on the information that they have. That's the point we're making - that those decisions are made not every day but on a regular basis in clinical contact. An assessment is made of how high this risk is and what decision will I make on foot of that assessment to admit or not to admit and so forth.

Deputy J. O'Keeffe: In relation to such decisions, there was one reference to such decisions being 97% wrong. Do you accept that?

Professor McGee: Certainly, they're 97% wrong. Clearly when somebody makes an assessment of suicide intent as a professional, they then act on it. So in many ways you change the context immediately by action. But, it's very difficult to predict suicide. This 97 out of 100 cases you're incorrect is partly because of how difficult it is. It's partly because there is immediately some kind of intervention to try to reduce the risk.

Deputy J. O'Keeffe: Is there any breakdown on that? I accept the point that if there is an intervention, the idea is to change the intent. To what extent is the 97% made up as a consequence of the immediate intervention? Is it impossible to say that?

Professor McGee: I think it is impossible to say that. I think what it is possible to say is that every day in this country actions are taken by mental health professionals about suicide risk. Although we know the predictability is very low, people are managed in various ways, including confinement against their will, because of an intention, a high risk of suicide.

Deputy J. O'Keeffe: If we accept that there is a 97% error rate, how then will it be possible for us to have a legal system which would be based on such clinical assessments which you say yourselves are, for one reason or another, so wrong?

Professor McGee: We currently have a legal system under the mental treatment Act which allows psychiatrists to detain people against their will for up to six months on the basis of an assessment of high risk of suicide. So we already have that system in place and that decision is taken regardless of whether somebody is pregnant or is the victim of child abuse or whatever the background circumstances are. The system that currently operates is a system which will in extremis take away somebody's liberty because while there isn't high predictability we are sufficiently concerned as a State to mandate health professionals, i.e. psychiatrists, to do that on our behalf in the interests of the safety of the individual. So that's already done. Although for other suicide risk, apart from that in pregnancy, we know that the predictability is very low, we still act in the interests of the safety of the individual.

Dr. Moane: That figure, to say that it's actually wrong I don't think is quite a right interpretation. What you're asking somebody to say is, given a case in front of me and accumulated over a number of cases, if I make a judgment that person will commit suicide then, as Professor McGee points out, there will be an intervention there. So, in actual fact, it's impossible to come up with a statement.

Deputy J. O'Keeffe: I accept, of course, you can't say it's wrong. Even the word "error" that I used is incorrect.

Dr. Moane: The only way you could judge it is to look at predictions where the clinician says this person won't commit suicide and then the person goes off and commits suicide. That, fortunately, as Professor McGee points out, is a very rare occurrence.

Deputy J. O'Keeffe: There is just one other question or issue. Your view is that abortion should be permitted here where there is a threat to the mental health of the mother posed by the traumatic impact of rape or incest. Taking the view that late abortions are dangerous to the health of the mother, you're talking about early abortion. Is it possible to have clear - proof is the wrong word - convincing evidence that, in fact, the pregnancy is as a result of rape or incest at that stage? How would you propose that that would be dealt with? Do you see that if there were such a provision that it could lead to a situation where many pregnancies that weren't welcome might, in fact, then be classified as such or attempts might be made thereat? How would you cover that?

Dr. Moane: Again, we're assuming that this decision would be made in a clinical context where somebody is presenting with a traumatic pregnancy which is based on rape. So the assessment would be based on the assessment of trauma. The actual event of the rape itself would be only part of that assessment. So the assessment of the trauma would be based on the kinds of assessment procedures I outlined earlier - measures, clinical interview and so forth. To ascertain the fact of rape would be based on clinical questionings about the event itself and so forth. Within that context we think that a clinician would be competent to make a judgment about whether rape had actually occurred. We haven't agreed, we don't agree on the idea or there needn't be a legal conviction or a kind of legal argument.

Deputy J. O'Keeffe: Who would certify? The clinical psychologist would then certify it. Would that be what you have in mind?

Dr. Moane: That's a possibility, but as I say our idea is based on the idea of the trauma rather than the actual rape. So perhaps if it were a legal requirement that there be a certification that a rape had occurred, that's something that would have to be worked out as to who, in fact, would do that. But we wouldn't actually see that as necessary.

Deputy J. O'Keeffe: You wouldn't be certifying then that the pregnancy was the consequence of rape. You would be certifying that there was such extreme trauma as a consequence of the pregnancy-----

Dr. Moane: Which is assumed to-----

Deputy J. O'Keeffe: -----which is alleged to have been related to rape or incest that you would then provide the necessary certification and you think that would be sufficient to allow an abortion to be carried out?

Dr. Moane: That's our position, yes.

Deputy J. O'Keeffe: Thank you.

Deputy Kirk: I am sorry for being late and some of the questions I ask might have already been dealt with. With regard to the assessment of individual cases purely on a professional basis - I'm divorcing it from the moral consideration where specific recommendations might be made from your point of view - do you find that an acceptable way of dealing with cases which might come before you?

Dr. Moane: It is the procedure for dealing with cases currently. All we can say is that in the profession the assessment of suicide is an area that has been advancing for decades. It's a very large area of research involving psychiatrists, psychologists and other areas of research where there is well researched understanding of risk factors, there are well established assessment instruments and there is trained clinicians asking the kinds of questions that need to be asked. So, I would certainly say, yes, psychologists are competent to make an assessment and, as I say, make a decision on that basis. As we said earlier, they do that all the time in the context of hospitalisation and-----

Deputy Kirk: Regardless of the moral consideration?

Dr. Moane: A psychologist would certainly be competent to make an assessment as to whether somebody who is suicidal, the degree to which there is a threat to life in the case of somebody who is suicidal, I would say definitely yes.

Senator Dardis: Thank you for your presentation. I wish to return to a point raised by Deputy O'Keeffe and approach it from a slightly different angle. If we assume that suicide is grounds for an abortion, the difficulty arises in the definitions, as you can appreciate. Coming at it from the angle where somebody presents themselves as being suicidal, is it possible or with what degree of accuracy is it possible to say that this person is not suicidal? In other words, by virtue of the fact that they would present themselves as suicidal, that could lead to a situation, as you can appreciate, whereby it would be used as grounds.

Professor McGee: Yes, indeed. We would certainly see that somebody who presents themselves as suicidal would be observed over a period of time. Without specifying what period of time, certainly it wouldn't be an instant consultation with a decision at the end of the consultation. As is the case in other assessment of suicide, it would be a case of observing somebody in a confined situation, probably in a hospital or clinic situation, over a period of hours or days to assess the seriousness of the intent and also, clearly we would want to put this on record, clearly to do something about the suicide intent as a first strategy towards managing the situation rather than seeing suicide intent as automatically leading to a request for termination.

Senator Dardis: There was another area which Deputy O'Keeffe explored and I would like a little bit more clarification on it. It's to do with the evidence on the clinical and statistical side regarding rape and the traumatic effect of rape. You're suggesting that there's a fair body of evidence with regard to that but there's a much lesser body of evidence with regard to the effects of pregnancy on the propensity to suicide and so on. To what degree is there clinical-statistical evidence in these areas?

Professor McGee: Do you mean in the context of rape?

Senator Dardis: No, leaving rape aside, in the context of pregnancy, per se, or even in the context of, well, you can extend into crisis pregnancy, obviously beyond that, but there seems to be, in your presentation there's much less clarity in my view with regard to the degree to which pregnancy would lead someone away from suicide, so to speak.

Professor McGee: Our view is that all of the evidence suggests that there is a protective effect during pregnancy. For what reasons, it's not clear. Our point simply was that the major study that's cited to date has been a study in England and Wales, published in 1991 by Appleby, showing a one in 20 risk of suicide for women who are pregnant compared to eight at a maximum who are not pregnant. In a more recent study in the US, that rate was one in three. The argument of those authors published in the American Journal of Psychiatry in 1997, their argument was that their statistics were probably more accurate because they had access to full autopsy information on most of the cases.

We are really making the point here that we accept that there is a lower risk, but in all of these cases there is some risk. So, we were concerned that there was a notion that pregnancy provided a blanket protection against suicide and that that was not the case. So that for small numbers of individuals, smaller than outside of the pregnant state, there would still be a risk to suicide. It is indeed, for those small numbers of cases, that we're trying to work out a system of wording so that all people are equally protected.

Senator Dardis: But I'm correct in assuming that there's a much lesser body of evidence with regard to the effect of pregnancy on suicide relative to the evidence that relates to traumatic pregnancy, rape, and so on. Am I correct in that assumption? What I'm getting at is that, rather than the----- I accept what you're saying to me, but it appears to me that there is a high number of clinical and statistical studies regarding rape and its traumatic effect and a much lesser body of evidence relating to the other issue.

Professor McGee: Yes, but there is also a much lesser body of evidence combining rape and pregnancy following rape and the psychological consequences there. So there's three, in a way. There's a lot of evidence on rape and the psychological aftermath. There's an intermediate amount on the risk of suicide during general pregnancy, and there's very little on the risk of suicide in pregnancy following rape. In fact, we have not been able to find any. There's evidence on people's preferences for terminations or not, but not on the risk of suicide in that particular group.

Senator Dardis: Thank you. You've answered the question.

Dr. Moane: Actually, there is also a lot of evidence on trauma following crisis pregnancy, not specifically suicidal, but trauma generally, so that would be another well researched area in psychiatry and psychology.

Chairman: Thank you very much. You've put a lot of difficult issues for us in focus on this subject. Professor McGee, you're an expert in the area of health services research. Is that correct?

Professor McGee: Yes.

Chairman: What type of research are you engaged in there?

Professor McGee: We look at quality of life in various health conditions and under various treatments and I also look at how people experience the health system. So, I do a lot of work in relation to patient satisfaction, for example, currently, how older people evaluate the services they experience in different health boards in the country. We have started a study which looks at the prevalence of sexual abuse in the community and what are perceived as barriers to effective treatment and care by those who have experienced abuse and by the public at large. So they are the kinds of studies that we are involved in.

Chairman: Have you clinical experience in the care of pregnant women?

Professor McGee: No, I have been involved in research studies looking at the psychological consequences of spontaneous abortion in the first trimester.

Chairman: So to that extent you do, in fact, on the research basis?

Professor McGee: Yes.

Chairman: Yes, you've answered my question indirectly. On the general submission, there was a submission to the interdepartmental working group which contained some papers outlining the position of the Psychological Society of Ireland both on abortion and suicide. Isn't that right?

Professor McGee: Yes, that's right.

Chairman: And then you've supplemented that with this note, which is interesting because it comments on the evidence we've heard and, in a sense, you've responded to the evidence we've heard.

On the question of rape and incest, and this in a way is one of the most difficult issues we have to face, I see you recommend that abortion should be permitted where there is a threat to the mental health of the mother posed by the traumatic impact of the rape or incest. I'm not putting it to you because it was a matter of law, but that would require an amendment to the Constitution. That would require a referendum on the interpretation placed on the current provision in the X case. Isn't that right?

Professor McGee: Yes, it would. That would go over and above the current provision of the X case. We would believe that, in terms of option seven, that we would support, where there is a serious risk to the mental health of a woman pregnant as a result of rape or incest, that there be access to abortion in that context.

Chairman: I don't want to put words in your mouth but, in a way, would your position be that that is a more compelling case, in a sense, than the suicide-based case, given what you've said about the research?

Professor McGee: There's less evidence of the extent of serious ... mental health in pregnancy in women who are raped because the numbers are smaller than there is in relation to suicide. I wouldn't like to make one person's traumatic situation have a greater priority than another's.

Chairman: That's fine. It's just to elicit your position. There was just one other point. Coming back to suicide, of course, psychologists can attempt to assess the risk. In the Irish clinical setting, the obstetricians who spoke to us did not see abortion or termination of pregnancy or induced abortion as a valid clinical response in the context of a suicide threat. How do you treat a suicide threat? Suppose you assess a suicide threat, you assess there's a risk there, how do you treat it normally? Perhaps Dr. Moane would like to take that issue.

Dr. Moane: As I said, if it's a serious suicide risk, that situation would nearly always be in a situation of psychiatric conditions such as serious depression, mood disorder or whatever. So that's the originating source of the threat of suicide. In that instance, hospitalisation, 24 hour monitoring and psycho-active medication would be immediate options and then therapy of various kinds and more specific suicide contracts. You have there a psychiatric case, and that isn't necessarily going to be typical, although it will occur, obviously, in the case of a pregnancy with the threat of suicide. You might not have that psychiatric condition. You may have it, but you may not have it. In that case, it's not clear that the treatment is going to ... the intervention can be directed at a psychiatric condition. In fact, if a threat of suicide is firmly of will based on the need for abortion as in, "I cannot live with this option", it seems to me that there would be no other option, that other options would obviously be against the will of the client, of the patient.

Chairman: Dr. Moane, you're an expert in clinical psychology and you've conducted clinics, presumably, with pregnant women and advised them on these options.

Dr. Moane: No I haven't had the experience of conducting clinics with pregnant women. My training is in the assessment area. I don't conduct a clinical practice with pregnant women.

Chairman: No, but you conduct risk assessment clinics, so you assess the risk.

Dr. Moane: No, I'm personally not involved in the assessment of suicide risk.

Chairman: But you've done research on the assessment of risk, so you're an expert on the assessment of risk.

Dr. Moane: Yes.

Chairman: And you've made the point to us this morning there always has to be a risk of suicide. That's what I'm taking from what you're saying. The difficulty I have is that, I don't see in the evidence before us so far how abortion is seen as a clinical option in the context of a suicide threat. I don't see the link there.

Dr. Moane: Well you're assuming there that the threat of suicide is directly linked to the crisis pregnancy through the fact that the individual feels that their life will not be worth living should they have to continue with this unwanted pregnancy and that in their mind the choice is between abortion and their own life, and that is how they are perceiving the situation. So, that it is slightly different from a psychiatric which is the more usual clinical example of abortion. There is a more wilful element in that situation.

Chairman: But in effect then what you are saying is that if someone threatened to commit suicide because they cannot have an abortion, the law must provide for abortion in that instance.

Dr. Moane: I do not know what the law-----

Chairman: I do not want to be unfair on you. I appreciate that the person concerned is under terrible pressure.

Dr. Moane: I do not know what the law is actually saying. But what I am saying is that in that instance the option of abortion is one that would presumably remove the threat of suicide. Is that not what you are asking?

Professor McGee: The threat needs to be evaluated professionally as a serious or real intent to commit suicide. I think in that sense, in relation to the question about the obstetrician in that setting, the advice would be coming from that person's colleague, probably the consultant psychiatrist, that this context posed a real threat to the life of this woman in the same way as a cardiologist would give evidence that a particular context would pose a real threat to the life of the woman.

Chairman: Deputy McManus, do feel free to ask questions. I want to resume asking a few questions.

Deputy McManus: It does take a leap of imagination for one to put oneself in the position of somebody who is so affected by a pregnancy that they feel suicidal. It is not possible to do it any other way except to use our imagination. But really, as I take what you are saying, there is the issue of the individual case of the patient-----

Professor McGee: Yes.

Deputy McManus: -----who has been professionally assessed. With the mental treatment Act we have an example of a precedent where we are empowering the professionals to make certain pinnacle decisions and to act accordingly. What you are saying is, there is one issue relating to the patient but there is also an issue relating to the professional which does require our attention. Is that correct?

Professor McGee: We have seen cases through the courts, and obviously as far as the Supreme Court, where there has been a professional agreement that there was a real intent to commit suicide. I think it was Dr. McKenna who gave evidence at this hearing that he had personally seen a case of serious suicidal intent in his hospital in the previous year. Is that correct?

Dr. Moane: Yes.

Professor McGee: There is evidence that this does happen and that professionals in the situation are clear that there are cases where women are simply not saying something in order to procure an abortion which they do not actually mean.

Chairman: Dr. Clare spoke to us about this. He said:

If I were to summarise, I would say that the only real reason that I am here, I think, and that you will find psychiatrists involved in this is, in a way, because, I suppose we have been drawn in to try and get people off the hook over this issue of a danger to the health and life of a woman who is pregnant and wishes to terminate the pregnancy, so who better than to get the psychiatrist to tell you that if this is refused, this woman will kill herself. Well, no such statement can be made with any great safety, whether the person making it is a psychologist, psychiatrist or a general practitioner.

That was the view expressed by Dr. Anthony Clare. I am just putting that to you so that you can deal with it.

Professor McGee: I do not want to paraphrase Dr. Clare. I would imagine, going back to Deputy O'Keeffe's comments, and the point that Dr. Clare is making is that it is difficult to make that statement with any great predictive power. Of course those statements are made all of the time by consultant psychiatrists about whether somebody is of serious risk of committing suicide and actions are taken under the mental treatment Act in that regard. So, I am not sure if the word "safety" is the most useful word in this context. I think he is probably talking about the predictive validity of those statements. It does not mean that actions are not taken on the basis of the information.

Dr. Moane: A psychiatrist would, for example, be making a decision that if I do not admit this patient this patient will commit suicide. That would be a similar kind of a decision-making process.

Chairman: The context in which he made that statement was the position that obtained before the 1967 Act in the United Kingdom. Before the 1967 Act, under a more liberal interpretation of the Bourne case, it was possible that psychological grounds could justify a termination in England before the 1967 Act broadened the law. That ground still exists in the 1967 Act. The point Dr. Clare made to us was that he did not accept the scientific validity of what was happening under the legislation and that in his view the issue was abortion on request or a rather restrictive arrangement. This is the difficulty that we have as a committee, when you introduce a category such as this in effect you open the availability of abortion in general terms but the category itself becomes very wide.

Later we will hear evidence from Northern Ireland. I look forward to that because this question arose and does arise in Northern Ireland as it stands. There has been a number of court cases in the North, a far greater number than have been heard here, where evidence from psychiatrists and psychologists has been admitted on this issue. It seems that when looking at it on a comparative basis from an international point of view that that stage prefigures the final introduction of abortion on request, which is a big ethical issue which convulses our country and has convulsed other countries as you know.

I still have a difficulty with this particular question. In the clinical literature, is the termination of pregnancy viewed as an appropriate treatment for a suicide threat?

Dr. Moane: I do not think the word "treatment" is quite the right word that should be used. What you would have is a clinical setting - there are lots of cases described in the clinical literature of this nature - of a pregnant woman who is suicidal and is threatening suicide. But of course this is in the context of the US or Great Britain where there would be non-directive counselling and options would be explored. If the client then at that point chooses to have an abortion then that is what will happen. You would not call the abortion a treatment in that instance, you would call it a decision that the client has made on foot of her condition that she has made herself in the context of counselling. The clinical context would be one where the counselling is provided.

Professor McGee: I would add that the clinician in that situation, if there is legislation, is not making the decision that this woman should have an abortion. The clinician is making the decision that this woman has a serious or real threat of suicide. It is then the legislation which permits the action that the woman herself decides to take. The psychiatrist or whoever it is in that setting is not prescribing abortion for a woman, they are simply outlining their clinical judgment of the mental state of that individual. It is the Legislature in that context which permits certain actions on foot of that. The psychiatrist is not prescribing.

Chairman: I appreciate that. They are making an assessment.

Senator Dardis: Surely the outcome is based on the assessment? The judgment-----

Professor McGee: One of the possible outcomes is based on the assessment. Clearly one of the other obvious outcomes is treatment for that suicide intent.

Chairman: Did you refer to the page where Dr. McKenna's evidence can be found?

Professor McGee: I think it is page 50 something. I do not know if I noted it. The point I simply wanted to make was that he did make reference to having seen a woman who was suicidal in the previous year in his hospital setting.

Chairman: Yes, of course.

Deputy McManus: A fear has been expressed about the idea of suicide being accepted as grounds for an abortion or legislated for - it is already in the Constitution in terms of the Supreme Court decision. Do you feel that it would become an open door in terms of people being able to access abortion willy-nilly or do you think that Irish psychiatrists would use their clinical judgment in a way that would ensure there was a genuine effort to focus it on suicide and not to be used as an excuse?

Dr. Moane: You would write up your case and judgment. You would present, in that case, on the basis of your assessment what you based your judgment on, which was obviously to some degree objective in the sense of risk factors, scoring on assessment instruments which are objective and then the actual content of the clinical interview, if there was high risk behaviour, changes or whatever. You would actually document the basis of your decision. My personal view is that it would be a very highly contained grounds for abortion if you're going to have a situation where a patient has to be assessed on these bases and documented and a team of some kind has to make a judgment about it and that's in the public domain and can be monitored. It could clearly be monitored.

Professor McGee: As professionals, we're in an era where we're slightly not quite such a small country any longer and I think there is increasing evidence that professionals are willing to challenge the actions of other professionals if they think they contravene the law of the land or ethical codes in their disciplines. I think there would be quite a strong policing by fellow professionals of the management of any kind of restricted legislation that was in place and I think anybody acting in that environment, as indeed some of the people who spoke already have said, in the current environment, people are very careful about acting within the law.

Chairman: I'd like to thank Dr. Moane and Professor McGee for their contributions and I'll suspend the session for five minutes until Dr. Lamki takes his place before the committee. Thank you very much.

Dr. Moane: Thank you. Actually, do you wish to have these documents presented to you?

Chairman: The document that was submitted to the interdepartmental committee?

Dr. Moane: Yes, and some leaflet literature and research papers.

Chairman: I have them and I'll table them before the Houses together with any papers you want to present. Thank you very much.

Professor McGee: These are just the ones that we thought were additional to what you've already heard about from other submissions so I've just left two copies of them.

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