Ethical arguments for access to abortion services in

Viewpoint

Ethical arguments for access to abortion services in the Republic of Ireland: recent developments in the public discourse Joan McCarthy,1 Katherine O’Donnell,2 Louise Campbell,3 Dolores Dooley4 1

School of Nursing and Midwifery, University College Cork, Cork, Ireland 2 UCD School of Philosophy, University College Dublin, Dublin, Ireland 3 Department of Anatomy, School of Medicine, National University of Ireland Galway 4 RCSI Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland Correspondence to Dr Joan McCarthy, School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland; j.mccarthy@ucc.ie Received 21 December 2017 Revised 23 April 2018 Accepted 26 April 2018

To cite: McCarthy J, O’Donnell K, Campbell L, et al. J Med Ethics Epub ahead of print: [please include Day Month Year]. doi:10.1136/ medethics-2017-104728

Abstract The Republic of Ireland has some of the most restrictive abortion legislation in the world which grants to the ’unborn’ an equal right to life to that of the pregnant woman. This article outlines recent developments in the public discourse on abortion in Ireland and explains the particular cultural and religious context that informs the ethical case for access to abortion services. Our perspective rests on respect for two very familiar moral principles – autonomy and justice – which are at the centre of social and democratic societies around the world. This article explains the context for the deployment of these concepts in order to support the claim that the current legislation and its operationalisation in clinical practice poses serious risks to the health, lives and well-being of pregnant women, tramples on their autonomy rights and requires of them a self-sacrifice that is unreasonable and unjust. Background

An Tionól Saoránach/The Citizens’Assembly was established in July 2016 by a resolution of both houses of the Oireachtas (Parliament) in Ireland as an exercise in deliberative democracy. The Assembly has a mandate to consider and make recommendations on a number of current topics of national interest and the Oireachtas is committed to respond to the Assembly’s recommendations in a timely manner. Membership of the Citizens’ Assembly comprises 99 citizens who are entitled to vote at a referendum and who are randomly selected to be broadly representative of Irish society. They are brought together for a series of weekend meetings to listen to and consider expert opinion on the issues to hand and to subsequently discuss and deliberate on their recommendations. The Assembly has a permanent Chair, a former Supreme Court Judge, the Hon. Ms. Justice Mary Laffoy and the work of the Assembly is supported by an Expert Advisory Group which prepares information and advice on behalf of the Citizens. There is also a steering group which is a representative group of members who, in consultation with the secretariat, Chair and Expert Advisory group decide on the formation of the meetings’ agenda and the selection of expert speakers. The proceedings are held in public and live-streamed, and all recordings and presentations are posted on the Citizens’ Assembly website.1 Any matters before the Assembly are determined by a majority of the votes of the members present Initial topics scheduled for deliberation by the Citizens’ Assembly included the challenges and opportunities of an ageing population and tackling

climate change. However, the very first topic to be addressed by the Assembly was the contentious proposal that Ireland might change the eighth amendment to Bunreacht na hÉireann/Irish Constitution, introduced in 1983, as Article 40.3. 3: “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.’ The eighth amendment of the Constitution was considered by the Citizens’ Assembly over 5 weekends from November 2016 to April 2017.2 Abortion has been a continuously debated and bitterly divisive topic in Ireland for over thirty years as both jurisdictions on the island of Ireland (that is the Irish Republic and Northern Ireland) have maintained abortion regimes that are among the world’s most restrictive and punitive. The deliberative democracy of the Citizens’ Assembly had been set an unenviable task as discussion on abortion in Ireland has been highly emotive and the status quo has been largely maintained since 1983 in spite of a mounting number of horrific cases that fell foul of the eighth amendment, coming to public attention.i The Assembly was given clear direction on the values by which they would conduct their business: they would invite diverse expert opinions and gain clarity on the detailed evidence that the experts provided as reasons for their opinion; the Citizens would comprehensively consider different viewpoints and their ultimate decisions would be the product of fair, collegial and reasonable debate among the Citizens, made for the benefit of the public interest, that is for all the people of the Ireland. A range of experts (medical, legal and ethical) as well as advocacy groups and relevant individuals were invited to make presentations to the Assembly regarding the eighth amendment and submissions were also invited from the general public.2 The pro-choice approach to the question of the moral status of the fetus was first explained and defended by Bobby Farsides at the Citizens’ Assembly on the seventh of January 2017.3 Farsides outlined different views on the moral status of the fetus for example, that some depended on shared religious beliefs such as the sanctity of human life doctrine or the concept of ensoulment and others depended on secular views about the intrinsic value

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See for example, Enright et al,13 Fletcher18 and Taylor.14

McCarthy J, et al. J Med Ethics 2018;0:1–5. doi:10.1136/medethics-2017-104728

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Viewpoint of humanness, or the view that the fetus had potential to become a fully-fledged person. She pointed out that these accounts of the moral status of the fetus are only compelling to those with a particular religious or a world view. For Farsides, because they are not subject to proof or scientific observation, to enshrine such views in law effectively means that they are imposed on those who do not share the religious or secular beliefs on which they rest. In addition, she argued that even if we were to agree about the identity and moral status of the fetus, further work is needed in order to determine how to treat the fetus when a conflict of interest arises in relation to the woman who is carrying it. She concluded that the pro-choice position rightly acknowledges the uncertainty and disagreement that exists in relation to the moral status of the fetus and she proposed that ‘in place of imposing a unitary approach on this most metaphysical of issues we should trust womenii to act morally and make choices that they can individually live with.’ McCarthy presented ethical arguments for a pro-choice position to the Assembly on February fifth by first outlining a standard account of liberal autonomy that acts as the foundation of other rights including bodily integrity, privacy and self-determination.4 Like Farsides, McCarthy argued that because pregnancy results in profound and irreversible physiological, psychological and emotional changes to her body, her sense of self and her life the pregnant woman or girl has a special moral claim to make decisions about whether or not to continue the pregnancy. Moreover, she emphasised that justice requires that it is practically possible for women and girls to access abortion services but that the existing legislation means that many thousands of women and girls must travel to the UK and other countries to access safe abortion services.iii Therefore, for women and girls living in Ireland who are poor or young, in the asylum system or in the care of the state, and women and girls who are unable to travel because of illness or disability must endure a double injustice because they are unable to travel and are, thereby, forced to continue an unwanted, dangerous or futile pregnancy and childbirth. As the pro-choice perspectives advanced by Farsides and McCarthy to the Citizens’ Assembly suggest, the eighth amendment to the Constitution, in attributing a right to life to the ‘unborn’, has given rise to legislation and policies that place unequal or disproportionate burdens on pregnant women and girls living in Ireland. We consider this legislation and relevant policies in the following section.

avoid waiting for the inevitable, but she was told that nothing could be done as long as there was a foetal heartbeat. Her condition continued to deteriorate and on October 24 she was diagnosed with sepsis and moved to the High Dependency Unit with the intention of inducing labour. However, on admission it was determined that she had already miscarried minutes before she arrived. Despite all efforts, her condition further deteriorated over the next few days and she died in the early hours of Sunday 28 October.5 6 Three separate reports into the circumstances that led to the death of Savita Halappanavar - the postmortem inquest report of Dr. Ciaran MacLoughlin,5 the Health Services Executive (HSE) Report carried out under the chair of Sir Sabaratnam Arulkumaran,7 and the Health Information and Quality Authority (HIQA) Report8 - all point to gross inadequacies in the basic elements of Ms Halappanavar’s care. The results of the post-mortem found that Ms Halappanavar’s death was caused by septic shock associated with a miscarriage and chorioamnionitis and the inquest subsequently concluded that she had died as a result of ‘medical misadventure’.5 The HIQA report concluded that there was ‘general lack of provision of basic, fundamental care, for example, not following up on blood tests, a failure to recognise that Ms Halappanavar was at risk of clinical deterioration and a failure to act or escalate concerns to an appropriately qualified clinician when Ms Halappanavar was showing the signs of clinical deterioration’.iv All three reports also acknowledged that the lack of intervention was of serious concern.v The HSE Report concluded that one of the key causal factors that affected the adverse outcome was the failure to offer all management options to a patient experiencing inevitable miscarriage of an early second trimester pregnancy where the risk to the mother increased with time from the point at which her membranes were ruptured. Specifically, the Report concluded that “there was an apparent over-emphasis on the need not to intervene until the fetal heart stopped together with an under-emphasis on the need to focus appropriate attention on monitoring for and managing the risk of infection and sepsis in the mother’.vi In his report to the Coroner, the Clinical Director of the National Maternity Hospital, Dr. Peter Boylan, stated that, had Ms Halappanavar’s pregnancy been terminated within the first 2 days of her hospitalisation, ‘it is highly likely, on the balance of probabilities, that she would not have died’.9 The HSE Report concluded that the law needed clarification as to what constitutes sufficient risk to warrant a termination:

Medical uncertainty and risk

The most well known case illustrating the impact of the eighth amendment on clinical decision-making practices in relation to the management of risk in continuing pregnancy is the story of Savita Halappanavar. This 27-year-old woman was 17 weeks pregnant when she self-referred to the gynaecology ward of University College Hospital Galway (UCHG) on 21 October 2012 with severe back pain. She was admitted to the hospital for the management of what was diagnosed as an inevitable miscarriage. When her membranes spontaneously ruptured very early on October 22, Ms Halappanavar asked the health professionals caring for her if she could be induced in order to ii

Our references to women and girls should be understood to include people of all genders who may become pregnant iii Between January 1980 and December 2016, it is estimated that at least 168 703 women and girls who accessed UK abortion services provided Irish addresses.24 2

There is difficulty in interpretation of law in relation to ‘what constitutes a potential major hazard or threat to mother’s life’. This needs clarification. The consultant clearly thought that the risk to the mother had not crossed the point where termination was allowable in Irish law on the morning ward round on the 24th.vii

Moreover, the Report concluded that the investigation team ‘were satisfied that concern about the law, whether clear or not, impacted on the exercise of clinical professional judgement’.viii iv

HIQA Report, p10.8 It is evident from the HSE Report (2013)7 that a ‘wait and see’ approach was adopted from Sunday 21 October 14.20 ‘wait and see what happened naturally’; Monday 22 October 08.20am ‘await events’; Tuesday 23 October before 6.00am ‘await events’ (p73). vi HSE Report, p73.7 vii HSE Report, p72.7 viii HSE Report, p76.7

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Viewpoint Savita Halappanavar’s death caused a national and international outcry and put pressure on Irish legislators to clarify the precise scope of the law in relation to abortion. Ironically, in the same week that Ms Halappanavar was in the Galway hospital, an expert group appointed by the Government was finalising its recommendations in response to a European Court of Human Rights judgement relating to a challenge taken by three Irish women (A, B and C) who had been unintentionally pregnant in difficult and/or life-threatening circumstances and had travelled to the UK for abortions.10 The European Court found that the human rights of C had been breached and it required the state to clarify by law and/or regulation when it would be permissible for a woman whose life was at risk to avail of an abortion in Ireland.11 The publication of the expert group’s report, combined with the general public’s repugnance at what had befallen Ms Halappanavar, led to the introduction of the Protection of Life During Pregnancy Act (PLDPA) in 2013 which specified more clearly the implications of the eighth amendment for determining access to abortion in certain circumstances. Guidelines for health professionals relating to the implementation of the Act further elaborate on how the PLDPA allows for doctors to provide an abortion if the fetus is not ‘viable’ (no definition is offered as to what this entails) and if there is a ‘real and substantial risk’ to the life of the pregnant woman or girl (when her life is clearly and substantially threatened or when a serious risk of suicide exists) which can only be averted by the termination of the pregnancy.12 The doctors are certified to carry out the procedure if “they act in ‘good faith’”, which is understood as being cognisant of the need to preserve foetal life to the extent possible.13 14 In short, the PLDPA provides access to abortion in very narrow circumstances that are congruent with the eighth amendment. However, it offers little to address concerns about women’s safety, health and autonomy. In situations where continued pregnancy poses risk, the provisions of the PLDPA and the accompanying guidance for health professionals prescribe that doctors can only certify that there is a ‘real and substantial risk’ to the pregnant woman’s life (and NOT her health) which would necessitate a termination.12 15 Such risks of death may be difficult - if not impossible - to quantify, especially given the challenge of distinguishing between risks to the pregnant woman’s life and risks to her health.16 Moreover, while individual doctors may indeed share any uncertainties they may have about risk posed by continued pregnancy to the life (or health) of a pregnant woman, the legislation places no obligation on them to do so. Nor does it require them to involve her in discussions about what risk might be acceptable to her. For many women, continued pregnancy carries very grave risks, for example, hypertension, preeclampsia, sepsis or the exacerbation of existing conditions, such as congenital heart disease, diabetes or cancer.ix Health professionals seeking clarification with regard to the provisions of the PLDPA will find little insight in the guidance offered by the Irish HSE National Consent Policy (2013) which is, similarly, constrained by the terms of the eighth amendment.17 In line with international best practice, the Consent Policy recognises that health professionals are obliged to secure the informed consent of competent adults prior to any medical intervention. However, the Consent Policy also states that while a pregnant woman’s consent is required (as in the case of ix

Several legal scholars have argued that the provisions of the PLDPA are unworkable on several fronts. See Enright et al13 and Fletcher.18 McCarthy J, et al. J Med Ethics 2018;0:1–5. doi:10.1136/medethics-2017-104728

any other adult) for any medical intervention, there is ‘significant legal uncertainty’ (due to the constitutional provisions on the rights of the ‘unborn’) regarding her right to refuse treatment in circumstances where her refusal would put the life of a viable fetus at serious risk.x The Consent Policy advises health professionals to seek legal advice as to whether they should apply to the High Court for guidance on the matter. Relevant factors for consideration include the level of medical certainty as to the risk to the life of the unborn and ‘whether the imposition of treatment would place a disproportionate burden or risk of harm on the pregnant woman’.xi The Consent Policy however is silent on any requirement to include the views of the pregnant woman in the decision-making process in these circumstances. In effect, the decision about risk to the life of the unborn and the risk of harm to the woman is a decision for the clinician alone to make. Several recent court cases confirm that a significant number of health professionals and the HSE interpret the responsibility for the decision in this way. This is borne out by the HSE’s refusal of access to an abortion and forcible treatment in 2014 of Ms Y, a suicidal pregnant asylum seeker and rape survivor,18 and by the attempt by the HSE through an emergency hearing of the High Court in 2016 (HSE vs Mother B) to compel a heavily pregnant woman who was seeking a natural birth to undergo a caesarean section against her will in order to vindicate the right to life of her unborn child.19 20 In sum, it is clear from the PLDPA and the Consent Policy that the reach of the eighth amendment extends far beyond the issue of abortion and that it has profound and dangerous implications for women and girls who want to continue with their pregnancies, as well as for women and girls who do not. In both cases, the principles of reproductive autonomy and reproductive justice place an onus on the State to ensure that the views of the health and life risks that women and girls feel able or willing to take in relation to their pregnancy are sought, respected and defended.

Alliance of church and state

Historically, any discussions of reproductive autonomy and reproductive justice have been largely absent from public discourse in Ireland. In addition to creating such a very broad and inclusive forum for the presentation and exchange of views on these topics, the Citizens’ Assembly also radically transformed the tone and parameters of the dialogue around women’s autonomy when it invited individual women to share their personal experiences of having to travel for an abortion to the UK or elsewhere.xii xiii Hitherto, the oppressive silence, the refusal to view women as moral agents in their own right and the shaming and marginalisation of individual women and girls who have had abortions is due to the long legacy of an alliance of the Catholic Church and state bodies that originally combined to govern the new Saorstát/Free State in the partitioned island of Ireland in 1922. The business of reproduction and women’s sexuality was the prime locus for the demonstration of the power and legitimacy of this first generation of the Irish establishment. Their ideology is evident x

HSE National Consent Policy, 2013, p41.17 HSE National Consent Policy, 2013, p42.17 xii The secretariat of the Citizens’ Assembly published 250 submissions from individuals and many of these told the personal stories of women who had had abortions.25 xiii The Abortion Rights Campaign included 60 personal stories in their submission.26 xi

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Viewpoint in how law and policy have purposefully and systematically controlled and exploited women’s sexuality, labour and bodies in the intervening decades. For example, ten Magdalene laundries operated with impunity throughout the country where girls and women were incarcerated in harsh conditions and forced to hard labour to atone for sins (the last Magdalene closed in 1996).21 22 In addition, because it declared unmarried mothers ‘a problem’, it ran Mother and Baby Homes for the confinement of these women, who often found themselves giving birth without pain relief.21 22 The children born in these homes were declared ‘illegitimate’ and died in disproportionately large numbers while infants; if they survived, were boarded out, sent to industrial schools or, after 1953, placed for adoption. One hundred years later, this establishment still holds significant sway when we consider how much of the Irish national education and health services continue the practice of being both state-funded and Church-run.xiv For most of the past century, the Irish establishment also denied access to contraception; some hospitals inflicted symphysiotomies rather than provide caesarean sections; access to sterilisation was forbidden and fertility treatment was, and still is, curtailed.xv When we consider these factors, we begin to apprehend the contours of reproductive oppression in twentieth-century Ireland.

Conclusion

The eventual recommendations of the Citizens’ Assembly surprised many on all sides of the political spectrum as they included repealing the eighth amendment and legislating for the regulation of abortion services that is in line with the majority of European countries.xvi A Joint Committee of both houses of the Oireachtas was convened to discuss the Citizens’ Assembly report and that Committee concurred with the Assembly that the Irish people should be asked by referendum to consider repealing the eighth amendment and to further insert a clause that will ensure that any future legislation on abortion is determined not by the constitution but the legislature.23 Following on the conclusions of the Joint Committee, the leader of the opposition in the Dáil/lower house of the Parliament, Micheál Martin, caused a political upset when he announced that he had changed his long-standing anti-choice position (established for many decades) as he had carefully considered the submissions to and the reports of the Citizens’ Assembly and the Joint Committee and he would support a motion to hold a referendum to repeal the eighth amendment. xiv

The vast majority (over 90%) of primary schools in Ireland are owned and under the patronage of the Catholic Church. The two main teaching hospitals of University College Dublin (ie, the Mater and St Vincent’s) are still run according to a Catholic ethos. xv Symphysiotomy is the cutting apart of the cartilage of the pubic bone. This operation, which is very rare in modern medicine, was performed in Our Lady of Lourdes Hospital in Drogheda until the 1980s, in preference to caesarean sections supposedly as the latter would entail that women would not be able to have more than two or three pregnancies and this would mean they would require contraception, in contravention of Catholic Church teaching. There is excellent work by historians on the status and oppression of women in the founding of the Saorstát. See for example Beaumont,27 McAvoy,28 Valiulis29 and Valiulis.30 xvi See First report and recommendations of the Citizens’ Assembly: the eighth amendment of the Constitution, 29 June 2017, pp3–4.31 This publication also includes an account of the context for the establishment of the Citizen’s Assembly as well as a description of the principles and procedures that underpin the working of the Assembly. 4

The Taoiseach/Prime Minister, Leo Varadkar subsequently announced that he too had changed his anti-choice position and the Dáil has set the 25th of May 2018 as the date for the referendum on repealing the eighth amendment. Contributors All four of the authors made a substantial contribution to the conception of the work, each draft, revision and approval of final content. JMcC wrote Draft 1 of the article based on contribution on reproductive autonomy from LC; contribution on Irish reproductive history from KO’D; contribution on morality and legality from DD. LC, KO’D and DD provided feedback and suggested amendments on 4 drafts and read final draft. All four authors agree to be accountable for all aspects of the work and ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Patient consent Not required. Provenance and peer review Not commissioned; externally peer reviewed. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

References

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