Friday, 16 November 2012
Savita’s tragic death is not a reason to change Ireland’s law on abortion
The ‘facts’ (yet to be confirmed) have been reported as follows:
‘On October 21, Savita Halappanavar visited Galway University Hospital, Ireland. The 31-year-old dentist was 17 weeks pregnant and suffering terrible back pain. Savita was told that she was having a miscarriage, so she requested an abortion. The doctors denied her request because they said that they detected a foetal heartbeat and that Irish law ruled out a termination. Savita’s pain continued for three days and she eventually died of septicaemia.’
The case has predictably evoked much criticism from the pro-choice lobby of the Irish abortion law, the Irish medical profession and the Catholic faith.
Savita’s death, on 28 October, is now the subject of two investigations by Ireland's Health and Safety Executive (HSE) and by University Hospital Galway.
I am reluctant to comment on the case itself before the full facts are established but there is a useful review of the medical management of mid-trimester miscarriage on Jen Gunter’s blog.
The judgement of whether there was mismanagement will turn ultimately on the actual sequence of clinical events and the management decisions made. Even then it may not be possible to know whether ending the pregnancy would have saved Savita's life.
Regardless, however, this case is not a reason to change Irish law or Irish medical guidelines because, even if inducing premature labour had indeed been necessary in order to save Savita's life, both law and guidelines would already have allowed this course of action. In addition many Christians, both Catholic and evangelical, would also have supported it.
The Irish law on abortion
Abortion remains illegal in Ireland under section 58 and 59 of the Offences against the Person Act 1861. However in 1983 the Irish electorate approved the Eighth Amendment to the Constitution of Ireland by referendum. It inserted the following paragraph into the constitution:
‘The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.’
In 1992, Ireland’s Supreme Court ruled that it had jurisdiction derived from the constitution to allow abortion in the case of a ‘real and substantial risk’ to the mother’s life. This right did not exist if there was a risk to her health but not her life.
So if the doctors caring for Savita had felt that the continuance of the pregnancy posed a ‘real and substantive risk’ to her life the current law would already have allowed them to induce the baby’s premature delivery to save her.
Irish Medical Guidelines
Section 21.4 of Ireland’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners would also have allowed this course:
'In current obstetrical practice, rare complications can arise where therapeutic intervention (including termination of a pregnancy) is required at a stage when, due to extreme immaturity of the baby, there may be little or no hope of the baby surviving. In these exceptional circumstances, it may be necessary to intervene to terminate the pregnancy to protect the life of the mother, while making every effort to preserve the life of the baby.'
At 17 weeks gestation the baby, even if it is alive at the time labour is induced, is too young to survive. But again Irish medical guidelines would not have stopped doctors inducing labour to save the mother's life.
In 2000, Professor John Bonnar, then chairman of Institute of Obstetricians and Gynaecologists, which represents 90%-95% of Ireland's obstetricians and gynaecologists, explained the situation to the All Party Oireachtas Committee's Fifth Report on Abortion as follows:
'In current obstetrical practice rare complications can arise where therapeutic intervention is required at a stage in pregnancy when there will be little or no prospect for the survival of the baby, due to extreme immaturity. In these exceptional situations failure to intervene may result in the death of both the mother and baby. We consider that there is a fundamental difference between abortion carried out with the intention of taking the life of the baby, for example for social reasons, and the unavoidable death of the baby resulting from essential treatment to protect the life of the mother.'
'We have never regarded these interventions as abortion. It would never cross an obstetrician’s mind that intervening in a case of pre-eclampsia, cancer of the cervix or ectopic pregnancy is abortion. They are not abortion as far as the professional is concerned, these are medical treatments that are essential to protect the life of the mother. So when we interfere in the best interests of protecting a mother, and not allowing her to succumb, and we are faced with a foetus that dies, we don’t regard that as something that we have, as it were, achieved by an abortion.
Abortion in the professional view to my mind is something entirely different. It is actually intervening, usually in a normal pregnancy, to get rid of the pregnancy, to get rid of the foetus. That is what we would consider the direct procurement of an abortion. In other words, it’s an unwanted baby and, therefore, you intervene to end its life. That has never been a part of the practice of Irish obstetrics and I hope it never will be.'
Speaking to the Irish Independent this week clinical professor of obstetrics and gynaecology at the Royal College of Surgeons in Dublin Dr Sam Coulter-Smith confirmed this view:
'I think most of us who work in obstetrics and gynaecology, there may be individual differences, but the majority would be of the view that if the health is such a risk that there is a risk of death and we are dealing with a foetus that is not viable, there is only one answer to that question, we bring the pregnancy to an end.'
There may be differences of opinion amongst Christian commentators about whether ending a pregnancy to save a mother’s life can ever be ethical. But I was interested to see, for example, that Catholic Voices have argued there is nothing in Catholic teaching that would stop such an intervention.
Personally I would see this as a choice between intervening to save one life (that of the mother) or standing by and allowing two (both mother and baby) to die.
And as Christian doctor, husband and father I would intervene. In doing so I would not be saying that the baby's life is less important than that of the mother, but simply (since the baby will die regardless) that in a desperate situation one must simply try to do the most good one can.
I have personally operated in an emergency to save the life of a mother with a ruptured ectopic pregnancy not knowing whether the embryo, who could not have survived anyway, was alive or dead. I would have no hesitation in doing so again. And in the situation where labour needed to be induced to save the life of a mother in an emergency (as in severe sepsis or eclampsia) I would induce it if I sincerely believed that nothing I could do would save the baby.
Often in such situations, even if the baby is premature, it is sometimes possible to deliver it alive in such a way that the parents can have some short time to bond with it and say their goodbyes. But, even if not, such bonding is equally possible after death.
Thankfully bringing a pregnancy to a premature end in order to save the life of the mother is vanishingly rare. In the UK it was reported in 1992 that in the first 25 years of the operation of the Abortion Act 1967 only 0.013% of all abortions were performed 'to save the life of the mother' and it is even questionable whether many of these required such radical action. The 2009 Abortion Statistics for England and Wales do not report a single case meaning this is a scenario that the vast majority of doctors, and even most obstetricians, will never face in a lifetime of medical practice.
So let’s not be bumped by this extreme case into arguing for a relaxation of the law and professional guidance in Ireland when the existing law and guidance do not actually prevent doctors intervening to save a mother’s life. That would be to start Ireland down the slippery slope to the situation in Britain where we have over 200,000 abortions per year with most performed on grounds of failed contraception, economic difficulty, social inconvenience or unwanted pregnancy.
No, let’s rather support Ireland in upholding a law which is actually the best in Europe for both mothers and babies. It protects babies from abortion with its blanket prohibitions and stiff penalties, whilst at the same time making allowance for intervention to save a mother’s life in an emergency when her baby cannot be saved. And rather than trying to legislate for every situation it allows the courts to dispense justice with mercy in hard cases. It does not need changing.