COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
OFFICIAL REPORT
(Hansard)
Guidance on the Termination of Pregnancy
17 October 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mrs Carmel Hanna
Witnesses:
Mrs Johanna Higgins Association of Catholic Lawyers of Ireland
Dr Lorraine McDermott Doctors for Life
Ms Margaret McCluskey Life Northern Ireland
Mrs Lynn Coles Silent No More
Audrey Simpson) Family Planning Association
Georgie McCormick) Family Planning Association
Pamela Dooley) UNISON
Grace Glenny) Family Planning Association
Dr Margaret Boyle )
Mr Martin Bradley ) Department of Health, Social Services and Public Safety
Mr Sean Holland )
Dr Michael McBride )
Mr Oswyn Paulin) Departmental Solicitor’s Office
The Chairperson (Mrs I Robinson):
Following a Court of Appeal judgement in October 2004, the Department of Health, Social Services and Public Safety was required to issue guidance to health care professionals to clarify the legal position on the termination of pregnancy in Northern Ireland and provide them with clinical and good practice guidance.
Today, the Committee will hear evidence from pro-life representatives, pro-choice representatives and departmental officials before considering its response to the draft guidance. Public consultation on the guidance finished on 22 September 2008, but the Minister has agreed to the Committee’s request for an extension. Members have been provided with a copy of the consultation paper in their packs.
The first evidence session today is with pro-life groups. Copies of their submissions have been provided to members. Further submissions from pro-life groups have been tabled for members’ information. It is my pleasure to welcome Johanna Higgins from the Association of Catholic Lawyers of Ireland; Dr Lorraine McDermott from Doctors for Life; Margaret McCloskey from Life Northern Ireland, and Lynn Coles from Choose Life Ministries. You are very welcome this morning.
I invite you to make a brief presentation after which I will invite members to ask questions. The session will last for approximately one hour, which is the same length of time that will be given to those who will be providing a different view.
Members have also been provided with a copy of a paper from the Royal College of Psychiatrists, and the Royal College has contacted the Committee to make it clear that it is neutral on the issue of abortion.
Mrs Johanna Higgins (Association of Catholic Lawyers of Ireland):
I am co-founder of the Association of Catholic Lawyers of Ireland, and all of our work is consecrated to the Immaculate Heart of Mary. I am a barrister at the Inn of Court of Northern Ireland, the King’s Inns in Dublin and the Inner Temple in London. I have been in practice at the bar for 17 years. My experience includes five years as a senior public prosecution lawyer and two years specialising in judicial review as a community care lawyer. In 2000, I acted for a pro-life intervener in the High Court judicial review that instigated the issue of these guidelines. I also published briefing papers on the draft guidelines in 2007 and on the consultation paper in 2008.
The issue before the Department is to explain the criminal law on abortion. Abortion is a matter of justice and criminal law and it should not be regarded as a medical issue per se. In this case, it is a matter of justice for the unborn child that the law should be stated correctly. The criminal law on abortion exists entirely to protect the unborn child; that is its one purpose. However, the departmental guidelines do not include a single mention of the victim, which, in this area of law, is the unborn child. That is a gross omission, to say the least.
If an attempt were made to define the criminal law on murder or domestic violence without mentioning the victim, there would, rightly, be a massive outcry. Therefore, we find it extremely disturbing that an attempt has been made to define the law on abortion without any reference to the victim. It is ludicrous: the unborn child must be treated as a proper person and be placed at the centre of the guidelines.
The law on abortion comes from the Criminal Justice Act ( Northern Ireland) 1945, which is a fairly recent piece of legislation. The Offences Against the Person Act 1861, in which illegal abortion is enshrined, also deals with murder, manslaughter, infanticide, assault, battery and all other offences against the person. To treat the law on abortion, which is part of that statute, with contempt by not properly outlining it and giving it due consideration undermines not only the law on abortion but the entire statute. It also makes a mockery of the criminal law and courts of this country.
If we do not ensure that the matter is dealt with properly, it will be only a matter of time before other laws are being undermined, and those who are currently protected under the Offences Against the Person Act 1861, such as the young and vulnerable and you and I, will also become victims of the liberalisation and undermining of the law.
I examined the numerous problems with the guidelines in my lengthy briefing paper to the Committee. However, they all stem from the initial problem that there has been a fundamental misstatement of the criminal law. The law has been presented wrongly; it has been presented upside down and back to front. It has not been dealt with in the way that a normal illustration of a criminal legal situation would be presented.
With that in mind, and to back up my submission, I contacted Professor John Keown, who is an international lawyer with expertise in the law of medical ethics. He was awarded a doctorate from the University of Oxford where, as a senior lecturer, he lectured on medical ethics. In fact, his book ‘Abortion, Doctors and the Law’ is one of the leading books, if not the leading book, on the history of abortion law in England. I asked him to study the Department’s guidelines and to provide a statement on his view of the way that the law had been addressed. He states:
“The opening paragraph of the Guidance … is seriously misleading”.
I will not read out his entire statement, because members have been given copies. However, he continues:
“The starting point of the Guidance should have been a clear statement of the illegality of abortion in Northern Ireland: that it is a crime punishable by a maximum of life imprisonment to use any means with intent to procure miscarriage, and an offence to supply means knowing that they are to be used with that intent. The Guidance should then have recalled the central if not sole purpose of this prohibition: the protection of the unborn child, a purpose which has informed the law against abortion for over 700 years. Only when the rule had been clearly stated should the scope of the exception have been considered. Similarly, the Guidance should accurately have stated the law against child destruction and its central purpose, the protection of a child ‘capable of being born alive’, and then have noted the narrowness of the exception to this prohibition: such a child may be intentionally destroyed for the purpose only of saving the life of the mother. (It is remarkable that paragraph 2.6 of the Guidance, which purports to quote the statute, misstates this exception by omitting the important word ‘only’.)”
Professor Keown continues on that topic, and members should have a copy of his letter in their information packs.
The Department has overstated the defence by putting it first in the guidance. Indeed, the Department has put the body of the law in a footnote, which is incredible, because to do so completely undermines the law and suggests to people that they should treat it as inconsequential — who reads footnotes? The Department has placed the exception — the defence — in bold at the top of the guidance, and has actually misstated it. That is advertising the defence, and will, inevitably, lead to more people committing the crime that the law intends to prevent from happening.
Another important legal error has been made in the guidelines in that they do not distinguish between the different defences to illegal abortion and child destruction. Illegal abortion is regulated by the Offences Against the Person Act 1861. That offence covers any child from conception to full term. The law on child destruction has a doubling-over effect and covers a child from when it is capable of being born alive to its birth. Those are two separate offences, and the defence to illegal abortion is wider than the defence to child destruction. However, the guidelines state:
“In other words the legal justification for carrying out a termination of pregnancy in Northern Ireland is exactly the same both before and after the time at which a child is capable of being born alive. This follows from the Bourne decision and its application to the Northern Ireland legislation.”
That is not true: it is legally incorrect; and Professor Keown agrees. If that statement is sent to doctors, it will lead to the direct, illegal abortion in Northern Ireland of children who are capable of being born alive. The exception provided in the statutory prohibition of child destruction — a child that is capable of being born alive — is strict and is applicable only when the mother’s life is at risk. The Bourne case does not apply to child destruction directly — a myth that is being perpetuated. A judge may take it into account, but it does not apply to that offence. It must be interpreted strictly.
The offence of illegal abortion is not as strict. A future court may follow the Bourne case, which extended defences to include therapeutic health reasons. However, that future court may choose not do so. However, the guidelines state, as a fact, that that will be a defence in all cases. That is erroneous — it should say “may” be a defence. The Department has stated the defences too widely, and, in the case of a child capable of being born alive, the guidelines are wrong. They quote directly from Lord Chief Justice, Sir Brian Kerr’s initial High Court judgement. However, that judgement was overturned by the Court of Appeal.
Therefore, it a mystery to me and to other lawyers why the Department insists on using a High Court case that is not legally binding and that has been overturned by a subsequent Court of Appeal ruling, especially given that the judge in the Court of Appeal case disagreed specifically with the statement of law made in the High Court. I have pointed that fact out to the Department on at least two occasions, and it does not have an explanation. However, Lord Lester, who represented the Family Planning Association (FPA) in the High Court, stated in court that Sir Brian Kerr’s acceptance of the law would be a good foundation for guidelines. The Health Promotion Agency — a body funded by the Department of Health, Social Services and Public Safety — subsequently issued a fact sheet that was written by the FPA, which was supposed to illustrate the law in Northern Ireland. However, that document contains the same errors, and offers the same explanation of the law, as the departmental guidance.
It appears that the departmental guidance follows the explanation of the law provided in the FPA document rather than an explanation based on independent legal advice. That is a worrying matter, of which I ask the Committee to take serious account.
Since last year, the Department has changed four points in the guidance document according to issues that I had raised about the previous document. During a meeting on 29 September 2008 with me, the Department also agreed to change a further point. The document had misstated the law on criminal child destruction, and the Department agreed that a full statement should be provided.
I also asked the senior medical officer, who was present at that meeting, whether it is ever necessary, on medical grounds, to inject potassium chloride into the heart of an unborn baby and deliver that child dead: the answer was no. Therefore, neither in legal terms, nor in medical terms can it be said that it is appropriate, necessary or legal to directly abort a viable child in this jurisdiction. It can never be said to be correct practice to directly abort a viable child in this country unless it is a medical necessity. The legal defence to child destruction is very narrow and applies only when it is necessary to save the life of the mother.
There is growing evidence that illegal abortion and child destruction have been happening in Northern Ireland. We have collected a number of pieces of information and material about that, especially on the issue of foetal abnormality. I have asked the Department to provide information on where the bodies of the unborn children who were aborted in this country over the last number of years have been disposed. The Department said that it will assist me with that.
It is important to note that the Corporate Manslaughter and Corporate Homicide Act 2007 is now in place in Northern Ireland. Under that legislation, any Department or employer can be said to be involved in the unlawful death of any person who is protected by the criminal law. As a result of their action, inaction or negligence, they can also be held criminally liable for any such death. I also made that point clear to the Department on 29 September.
The guidelines must be rewritten with reference to criminal lawyers and the unborn child. The guidelines must also make a clear statement about the two very serious offences, and that in both cases the maximum sentence is life imprisonment. In the past year, a woman who lived in England was convicted of the destruction of her unborn child and was successfully prosecuted in a court in Manchester. That was a very serious situation, and such things will happen if the guidelines go ahead.
The Association of Catholic Lawyers of Ireland is examining a judicial review based on the opening lines of the guidance, which I have already said are completely erroneous. We intend to pursue that option if the guidelines proceed in their present format. That is an overview of the main points included in my briefing paper.
Dr Lorraine McDermott (Doctors for Life):
I have been a GP for 13 years, and I represent Doctors for Life, which is a group of medical professionals who support the right of life from its beginning at conception to its natural end. The Hippocratic tradition has always maintained that a doctor treating a pregnant woman has a duty of care to two patients, the mother and the child. Advances in medical care mean that the circumstances in which a woman’s life is genuinely threatened by being pregnant are now exceptionally rare.
In medicine, a doctor’s first duty is to do no harm. Therefore, doctors acting in the best interests of their patients should only authorise or recommend abortion in the most extreme circumstances and never with the explicit intention of ending the life of the unborn child.
We want the guidelines to make some attempt to categorise the medical conditions for which a termination might be considered into cardiac, respiratory, renal vascular, gynaecological or malignant. That would provide a guide for grade 2 practitioners as to the severity of what conditions might be involved. It would also be useful for auditing purposes.
The treatment should be carried out by an appropriate consultant in the specialty concerned; the aim being to maximise the chances of survival of the woman and the child.
Members have been provided with a copy of a statement given to us by our colleagues in psychiatry. In it, they say that they believe that it is rare for pregnancy to cause adverse effects on the mental health of the woman that are real, serious, long-term or permanent.
In cases of pregnancy associated with depressive illness of such severity that there is a real continuing threat and likely probability of suicide occurring, an appropriate consultant in either adolescent psychiatry or mental-handicap psychiatry should always be involved. In such a serious situation it should certainly not be, as the termination of pregnancy in Northern Ireland guidelines instruct, an obstetrician or a general practitioner.
If a pregnant woman is suicidal, she should be assessed and treated with the same concern as a non-pregnant suicidal patient. She should be treated with medication, support, and, if necessary, hospital admission. If that is not done, the underlying mental-health problem will not be addressed.
The involvement of someone other than a consultant psychiatrist in the assessment can leave that person open to legal challenge. There is a great deal of evidence to suggest that pregnancy has a protective effect against suicide and that abortion has a significantly exacerbating effect on depression. Doctors for Life can provide several references to support that evidence.
As we have limited time in which to make our presentation, I will move on to the next section, which is about conscientious objection. Doctors for Life has no problem with looking after women who have to have terminations in emergency situations, but we disagree with the existing guidelines and the stated opinion of the Department, both of which contend that health professionals should be providing general care, and that they cannot express their conscientious objection in those cases. That position underestimates the extent and depth of revulsion at what can happen. The long-term health of some health professionals will be affected if they are forced into situations in which they have to take part, not only directly with abortions, but in the preparations for them.
I will now move on to the issue of consent. A woman can only give valid consent if she is fully aware of the facts of the abortion, the procedure involved, the potential development of the child and the physical and psychological problems that might arise, and the alternatives that are available. Doctors for Life feel that there is a great deal of information in the form of references and studies that have not been taken into account in that regard. The same goes for the issue of breast cancer. Written information should be provided so that the woman can have time to digest it.
GPs in Northern Ireland should never be put in the position of having to refer women to outside agencies or services, which is something that may be interpreted from the wording of the guidelines. Women who do not fit the strict criteria for termination under the law would fall into the counselling provisions. Therefore, GPs will have to determine whether a woman needs counselling or specialist referral where it is likely that a termination is being considered.
At this point I will refer members to paragraphs 4.2, 6.1 and 6.2 of the guidelines. At a meeting with the Department, we were assured that doctors in Northern Ireland will not be required or expected to provide information on how to access abortion services here, in Britain, or elsewhere, that do not fall within the remit of existing Northern Ireland legislation. Any other advice would be in breach of Northern Ireland legislation. Doctors for Life have an email from the General Medical Council (GMC) agreeing with that position. It is an important fact that has been left out of the guidelines.
Any other advice would be in breach of Northern Ireland legislation, and we received an e-mail from the GMC expressing agreement with that. That is a very important fact that has been left out of the guidelines; the guidelines contain an excerpt from GMC regulations that does not make that clear. Any medical professional reading those guidelines would assume that if they had a conscientious objection to abortion, they would have to refer the patient to an outside agency; that is illegal. That needs to be clarified. We can provide a copy of the GMC’s clarification of that point.
Finally, and very importantly, the Department of Health does not seem to have any definite plans for the audit of abortion record details. Detailed records must be kept, as in other areas of medical practice. We would like to see at least an annual audit of the number of abortions, the reasons for them, and, if necessary, a list of practitioners, if the numbers seem to be increasing, to ensure the legality of the abortions. If that is not done, the guidance will be meaningless.
Dr Deeny:
Thank you, ladies; I am delighted that you have raised that point. I make no bones about it: I too am pro-life. I have been a doctor for 28 years and have spent all my time trying to save lives rather than destroy them. Therefore abortion is at odds with what I am qualified to do. That said, I believe that the mother’s life is paramount. I accept that there are situations — albeit rare — in which termination must take place to save the mother’s life. I am delighted that you have reassured me on the view of the GMC; I would like a copy of that correspondence for this afternoon’s presentation from the Department, if you do not mind.
I worked in Scotland for a year and in Australia — countries where arranging an abortion was as simple as making a phone call. In a feature about the celebration of Marie Stopes in one of the national news programmes on Monday night, Giles Brandreth told us that one in three women across the water has an abortion. That is a phenomenal number.
Years ago, a lady came to me to arrange an abortion; as a conscientious objector, I told her that she would have to go elsewhere. I looked at her case and saw that that would have been her second abortion in thirteen months. She wanted it to be organised between her shifts at work, as she did not want her employers to find out. We are now faced with calls for the extension of the 1967 Abortion Act to Northern Ireland. I am not a member of your group — perhaps I should join — but I have spoken to colleagues this week, and many GPs in Northern Ireland do not want the Act to be extended to Northern Ireland. For this lady, getting an abortion was simply a matter of convenience; she was very nice about it, simply wanting it done for the second time in just over a year and at a certain time, like having a tooth extracted.
People are entitled to their views, including those who are pro-choice, but the argument is often used that it is a woman’s body and she can do with it as she pleases. I am delighted to see four ladies here because it has been said publicly that it is grey men in this Building who are trying to prevent the law being extended to Northern Ireland, yet here we have women standing up for unborn children. I am delighted to see the four of you here, and I would like to know what you think about that argument. Two bodies are involved — you spoke about two patients, and I could not agree with you more — one totally dependent on the other.
The baby is totally dependent on the mother, but it could have a different skin colour or different blood group. I dispute the argument that it is the woman’s body and that she should be able to do with it as she wishes, as in other so-called developed countries — although how a country can be called developed when it allows the killing of the unborn is beyond me. I dispute that argument completely: two separate bodies are involved. The mother’s life is paramount, but the baby depends on the mother.
Even if that argument were correct, we are not allowed to self-mutilate. It could be compared to someone asking me, as a doctor, to remove their eye because they did not like it. Even if that argument is correct, it is no justification; you cannot decide to have your arm removed or your eye taken out.
The argument that a woman’s body is her own and that others, including doctors, should not be able to stop her doing what she wants with it is used by those who want the Abortion Act 1967 extended to Northern Ireland. What do you say to those who use that argument?
The Chairperson:
To clarify, we are here to discuss the legality of the Department’s guidelines rather than the emotive issues that surround abortion. However, I accept what Dr Deeny says, and if any of the witnesses want to respond, please do.
Dr McDermott:
If the Abortion Act 1967 was extended here, about 6,000 unborn children would be killed every year, which is appalling. Medical practitioners are always conscious that a female patient who is in her reproductive years may be pregnant. When prescribing drugs, for example, it is in the back of a medical practitioner’s mind that he or she could be dealing with two people. Just because a child is unwanted or is inconvenient, a doctor cannot say that he or she is dealing with one person. Once a woman is pregnant, she is past the stage of saying that she is on her own.
Mrs Higgins:
I made the point in my briefing paper that if doctors do not take into account that they are dealing with two patients when an unborn child is involved and if they do not deal properly with the unborn child, they could be acting negligently. There is case law in England where children who were dealt with improperly during pregnancy have sued health boards. In this jurisdiction, a child in the womb is protected and is a person under the Offences Against the Person Act 1861 and is protected against an act of child destruction — a child is not just a part of a woman’s body.
Legal academics, including John Cowan, have said that, extending the Abortion Act 1967 will medicalise abortion law and change the status of the unborn child from being a person to being a part of a woman’s body. However, in this jurisdiction an unborn child is regarded as a person under the law and is protected by the law. That is a clear statement of the legal position.
Mr Easton:
I am pro-life, except in cases where a mother’s life is in danger. Are you saying that practices in Northern Ireland are illegally carrying out abortions where an unborn child’s disability is used as an excuse to say that a mother’s life is in danger?
Mrs Higgins:
Yes. In his evidence to the All-Party Oireachtas Committee on the Constitution in 2000, Dr Lamki from the Royal Maternity Hospital said that foetal-abnormality abortions were happening in his hospital and that mental-health reasons were used to get around the law. However, most of the 80 babies a year who are aborted in this country have foetal abnormalities. That is on record, and it is not privileged information because it was stated in the Oireachtas. One of the pieces of evidence that we have is that those abortions are happening in the Royal Maternity Hospital.
Mr Easton:
Is there provision in the guidelines to help women who decide not to go to England for an abortion, for example, counselling?
Dr McDermott:
That is what we are trying to provide — two of the ladies beside me are counsellors in that area.
Mr Easton:
Is such support in the guidelines?
Dr McDermott:
That is what we need. There are two types of groups that require counselling. The first group comprises those women who have had a termination in order to save their lives. A termination in those circumstances is not regarded as an abortion by doctors; instead, it is regarded as necessary treatment, which challenges the need for the legislation. There is no problem with such an operation.
If you do not deal with the mother’s life, you lose the baby as well. We are not saying that there is never a case for termination.
There is a group of people that need counselling in dealing with the fact that they are having a termination, and there is another group that needs counselling on other options; for example, on what can be done to enable them to carry their pregnancy to term. That group needs to know that financial and emotional support is available and that there are houses where they can stay if they do not want to keep the baby and that the child can be adopted or fostered. Everything that can be done must be done to ensure a good outcome for both parties.
Mr Easton:
Is that in the guidelines?
Dr McDermott:
No.
Mr Easton:
It should be.
The Chairperson:
We are here to talk about the deficiencies, or otherwise, in the guidelines that the Department has issued for consultation.
Mrs Hanna:
Good morning, ladies; you are very welcome. I am aware of the difficulties in definitively diagnosing a severe physical or mental handicap, but I will give you the hard-case scenario: if a child is diagnosed with hydrocephalus, do you feel any unease about the fact that the mother is put in a very difficult position? How would you deal with that?
Mrs Higgins:
The law here does not allow for the abortion of a person who is hydrocephalic; the law regards that child a person. There is no differentiation for disability and the child therefore, whether it is disabled or not, will be fully protected by the law as it stands. If, during a scan, which usually happens at 22 weeks, information is given about the child’s disability, terminating that pregnancy is automatically an act of child destruction. Under the case law of C v S, a child is capable of being born alive from 21 weeks onward.
I have illustrated that a lethal injection to the heart, which is the direct abortion of a child with foetal abnormality, is illegal in this country. Before the Infant Life (Preservation) Act 1929, which is child destruction in England, was decoupled from the Abortion Act 1967, the physician David Alton said in Parliament that he was referring a case to the Attorney General. He had found that a lethal injection to the heart had been administered to an unborn child who was capable of being born alive. The legal position is very strict, and the counselling position for women who find themselves in that situation, which the doctor and the other ladies present will know more about, should be provided for in the guidelines.
Mrs Hanna:
I am just putting across the hard case, as that is the case where a woman or anyone dealing with that woman might have some unease. It is a very difficult scenario.
Dr McDermott:
You are dealing with a child. If that child was outside the womb, would things be done differently? If that child was severely disabled, would their life be terminated? You have to do everything that you can to treat the situation.
Mrs Lynn Coles (Choose Life Ministries):
In the past three years I have counselled two women with post-abortion trauma following a foetal-abnormality abortion. That situation requires the most complex of counselling. Women who have had abortions, including myself, have taken the lives of their children and are going through a grieving process. In the case of foetal abnormality, the woman takes the life of a sick child, which is far more complex. When women come to me following a foetal-abnormality abortion, I often seek advice from more senior and experienced counsellors.
I have also dealt with women who have decided to carry their baby because if a baby is severely handicapped, the chances are that the woman will not carry to term and will naturally miscarry. The loss of a baby through miscarriage is completely different from abortion, which is sudden and is the destruction of the child. Physically, the body deals with it differently. I have known a girl carry to term, under extreme pressure from family to abort, because they thought that it was the best thing for her. That baby lived for only a couple of days.
However, the mother would say that she had the child for a few days and that —
Mrs Hanna:
I know exactly what you are saying.
Mrs Coles:
It is a more natural grieving process.
Mrs Hanna:
She would say that at least she had that baby to hold for those couple of days.
Mrs Coles:
Absolutely.
Mrs Hanna:
Thank you; that has been helpful.
Mr Buchanan:
As one who is strongly pro-life, I am alarmed about some of the things that you say are missing from the guidelines but which must be included in order to protect the unborn child. By way of a comment more than a question, that is something that the Committee must stringently scrutinise to ensure that the Department is up to scratch when it draws up the new guidelines.
All those areas must be covered by the guidelines to ensure the protection of both the mother and the unborn child. An abortion can often seriously affect a mother. I have read mothers’ descriptions of horrendous post-abortion ordeals because there was nothing in the guidelines to alert them to what happened after their abortion. That is an area in which your evidence shows that the guidelines have failed. The Department’s new guidelines must address all those areas of concern.
Ms Margaret McCloskey (Life NI):
I will talk about the importance of counselling.
The Chairperson:
Will the witness speak up a little? I apologise for the sound system; it is appalling.
Ms McCloskey:
I hope that members can hear me now. I thank the Committee for the opportunity to address it about the importance of counselling, regardless of the period of gestation, for women who experience pregnancy crisis and who consider terminating their pregnancy.
For the past seven years, I have facilitated pre- and post-abortion counselling on behalf of Life Northern Ireland, an organisational member of the British Association for Counselling and Psychotherapy (BACP). Before coming to Life, I had 14 years’ experience as a registered general nurse, midwife and sick children’s nurse with special responsibility for the sick and premature neonate. During that time I worked in many centres of excellence in Scotland and in Northern Ireland.
I have worked in ante-natal clinics and in labour wards, in which I delivered 1,005 babies and was involved in the surgical delivery of many more; I have also cared for prematurely born babies. My experience as a nurse and a midwife, coupled with my experience as a counsellor, afford me a unique insight into the pressures faced by staff who must impart sensitive information in a time-limited and often pressurised environment. I have seen the emotional conflict experienced by patients who try to take in the information that they have been given or who consent to procedures in the face of bad news or a challenging, possibly life-altering, diagnosis.
Medical, midwifery and nursing staff fulfil specific roles that are governed by the ethical and clinical parameters set out by their employers and the professional bodies to which they belong. Their work is clinically driven and it requires patient compliance in order to achieve the best outcome. They may be perceived as authoritative and focused on the illness or the condition that requires correction or cure rather than as embracing their patients’ emotional or psychological needs. Therefore they may be regarded by the patient as distant rather than neutral — not as someone with whom a patient could share their distress, as they would with a counsellor.
It is for those reasons that it is essential that women in pregnancy crisis, especially those considering termination of pregnancy, are provided opportunities for person-centred, non-judgemental, non-directive counselling. In order to ensure that there is no conflict of roles it is important that counselling be facilitated by an independent, appropriately trained person who is not involved in hands-on patient care or in making clinical decisions.
The purpose of person-centred counselling is to focus on what the client brings to the session and to create a safe, non-judgemental environment in which the client is enabled to talk about the distress or concerns that she is experiencing from her point of view. It provides the client with time to identify, specify and clarify her issues of concern without influencing her towards a particular decision.
Issues of concern to the client may include alternatives to the termination of pregnancy and how she may be affected emotionally, physically or physiologically by the procedure that she may be considering. It may also be the place where the client seeks relevant, factual information about how procedures are done, and, depending on the period of gestation, what happens to the baby afterwards. In my experience, women who are facing dilemmas around pregnancy and who are considering the termination of a pregnancy rarely undertake the decision lightly, even those women who believe that the termination of a pregnancy is the correct and only decision open to them. Most feel that they are on the horns of a dilemma, pressured and influenced by those around them and yet isolated by their situation.
In order to provide holistic, individualised patient care at the highest standard required for good practice, mandatory provision of counselling for those who are considering termination of pregnancy is essential. It should be recorded as part of the clinical provision for care and should be signed off by the consultant in charge of the patient’s care, the patient and the counsellor who facilitates the session. Women who have pre-existing documented evidence of mental ill health or psychiatric disorder should be seen by a psychiatrist before having counselling. Those patients who have pre-existing medical or physical disorders that may be made worse by pregnancy should be seen by an expert in the field before receiving counselling. Women who decline counselling should be made to sign an against-medical-advice form that should be retained in the patient’s notes.
The option of post-abortion counselling as part of the care offered to women who are considering or who have had abortions would be very important to the holistic approach to patient care, especially for their emotional and psychological recovery. At least one third of the women with whom I come into contact through my work with Life NI request post-abortion counselling. When they describe the conditions under which they have consented to the termination of a pregnancy, many of them often regret that they did not speak to someone before going ahead. Many are devastated by the impact that their decision has had on them and their ongoing relationship with their families. They had no idea how they were going to feel afterwards, and now they realise that there is no way back. Post-abortion counselling is about providing the client with the time and space to come to terms with the decision that they have made, helping them to re-evaluate what they want for their future and signposting them to additional help from their GP if they are feeling low or depressed after the abortion.
Some women who had abortions many years ago and who have never spoken about it have flashbacks and nightmares. They may experience episodes of depression at anniversaries where they are consumed by guilt about their decision to terminate and are bereft at the loss of their relationship with their child. My experience has shown me that it is not only women who are directly affected by decisions on abortion, but also their spouses or partners. I feel that, under the proposed guidance, consideration should be given to providing counselling opportunities for them also.
Life NI has been facilitating person-centred, non-directive pre- and post-abortion counselling for women for the past 28 years and is ideally placed to partner the National Health Service in Northern Ireland in ensuring that women are afforded every opportunity to be fully informed, to have time to think, to reflect on the choices available, and to talk to someone who will listen without prejudice. In conclusion, the proposed guidance should reflect the requirement for the mandatory provision of independently facilitated, person-centred, non-directive counselling for all women who are considering termination of pregnancy or those who have had abortions and are finding it hard to come to terms with their decision. Thank you.
Mrs O’Neill:
You are very welcome; thank you for your presentation. I want to ask about conscientious objection. Lorraine said, I believe, that the guidelines are wrong insofar as they state that people cannot opt out of providing general care. If a woman has had an abortion elsewhere and finds herself in hospital and needs care —
Dr McDermott:
That is not a problem. We are talking about the situation before the termination when medical nursing staff or others have to clerk in a patient knowing that they are going to have a termination. If the guidelines are strict and if terminations are happening only in necessary situations, conscientious objection is not an issue.
We are talking about people not being allowed to object conscientiously to clerking in patients who they know are going to have terminations. It would be difficult for those staff to deal with people in such a situation.
Mrs O’Neill:
Therefore, as things stand with the law here, would abortions happen only in emergency or extreme situations?
Dr McDermott:
Yes, and that would be no problem. There should be no need for conscientious objection under those circumstances.
Mrs Higgins:
The guidelines do not specify what exactly the word “abortion” means; therefore we do not know whether it is used as a medical or a legal term. In law, there are different interpretations of “abortion”, and I am sure that in doctors’ practice “abortion” means different things. Therefore no doctor who is against abortion would have a problem with, for instance, the premature delivery of a child in a pre-eclampsia situation, where the pregnancy was terminated by the delivery of the child and both patients would be cared for. There would be no difficulty in that case.
It is in a situation such as giving a child a lethal injection to the heart, which is the direct and deliberate killing of the child, that doctors, nurses and other medical staff who have conscientious objections will have difficulties with the guidelines. The law is clear that that should not happen, but it seems that it does. The guidelines, on the face of them, seem to suggest that people will be forced to attend such situations.
The Chairperson:
From a Christian standpoint, and as a born-again Christian, the ethos and core of my belief is the protection of life and that no one — but no one — has the right to take life. In which areas do the draft guidelines need to be tied down to ensure the protection of the unborn child? We have to get the guidelines right and make them very clear, because they will have repercussions across the medical profession if they are not right. Where do the guidelines need to be tightened?
Mrs Higgins:
The law must be addressed in a straightforward way: explaining the difference in law between an act of child destruction and an illegal abortion; that the sole purpose of the law is to protect the unborn infant in the womb; and when the rule has been clearly stated it should be explained that the penalty for breaking that rule is life imprisonment.
The exceptions to the two separate offences should then be considered. The exception to the illegal abortion offence is slightly wider and may provide for therapeutic abortion. The exception to the child destruction offence is narrow; it may only be done to save the life of a child.
It must be remembered that we are talking about children who are capable of being born alive; about infants who would survive if they were delivered and were given proper pre-natal care, even if they were prematurely delivered due to an emergency, such as their mother being in danger. The law must be very strictly interpreted in that regard, so the case law needs to be examined in its entirety. Doctors must be informed that criminal lawyers will not accept the statement in the guidelines that civil cases are binding in criminal courts. That is simply not true.
The High Court cases on which the guidelines have been based are not binding in criminal courts. Doctors who carry out these procedures will face a judge in a criminal court with prosecution and defence lawyers, and a jury will decide whether they are innocent or guilty. The opinion of the doctors is not enough to satisfy the law. Even if their opinion is that the abortion in question is legal, the court will ultimately make that decision. Doctors sometimes fall into the misconception that the courts will automatically agree with their medical opinion. The law is very strict — it either is legal or it is not. The prosecution must present a case to prove that the doctor has committed an illegal act.
This should all be clarified in the guidelines, so that doctors are entirely clear about it. As Judge Nicholson stated, doctors should be provided clarity in relation to matters such as rules of evidence; what proofs will be required; and what protection they need — for example, that they should be able to refer to lawyers if they encounter conscientious-objection difficulties — to stop themselves being put in positions in which they may be incriminated if they proceed along certain lines. That is extremely important.
If the law is addressed properly and then it is given to doctors to implement clinical practice around that, most of the difficulties that we are addressing today will be resolved by that proper and clear statement of the law. Professor John Keown explained that putting the defence so obviously upfront is misleading and swallows the rule of law. The offences of abortion and child destruction might as well be scrapped if people believe that this document contains a correct statement of the law.
The Offences Against the Person Act 1861 also applies in Australia, where abortion has recently been totally decriminalised. As Dr Deeny noted, guidelines were introduced there some years ago, under which abortion was available almost on demand, even though abortion was illegal until last week. If we take the wrong route with the law, abortion legislation will be liberalised and there will be no law left. One cannot undermine a legal statute in that way and still expect it to be adhered to.
I also pointed out to the Department that the guidelines should contain a very clear statement as to what staff should do if they think that somebody else is breaking the law. That is not addressed in the guidelines, even though they are supposed to be a guide to the criminal law. What does a nurse do if she feels that a doctor or another member of staff is breaking the law? Is there a procedure for people to follow? I am sure that there is a procedure for other cases, such as cases of assault, for instance. That should be made clear in the guidelines.
Dr McDermott:
The guidelines say that the grounds for termination have to be
“real and serious, long-term or permanent”.
There is a problem with the word “serious”. Everyone’s definition of “serious” is different. It should be stronger that that — it should say “life-threatening”.
The Chairperson:
There are clearly deficiencies in how some matters have been addressed in the guidelines. There seem to be an awful lot of grey areas that could be interpreted very differently by different sections of our community.
Mrs Coles:
I am the regional co-ordinator of the Silent No More awareness campaign. I am a post-abortion woman, and I gave a presentation to the Department of Health about several related matters. I am concerned that the Department has no regard for women who have had abortions and that it does not offer counselling to women who are seeking abortions. Consequently, my presentation covered mental-health assessment; informed consent; the link between abortion and breast cancer; abortion survivors, including sibling, twin, and disabled survivors; and secret abortions for girls under 16 years old.
On 21 September 1980, I aborted my son, Stephen. I chose abortion, and I underwent a safe and legal procedure. Nevertheless, that choice was based on misinformation and fear. I often hear that poverty is an issue, and that poor women are forced to travel to England because they cannot afford to bring up a baby. I was faced with the threat of losing my job, which demonstrates that poverty can be a coercive factor. A poor woman who has had an abortion is still poor; nothing has been done to alleviate her poverty.
In my circumstances, I chose to have an abortion. I had no counselling, and I went back to work the following day. For 10 years, I denied that I had had an abortion, until I received counselling and realised that, during those years, I had clearly been suffering from post-abortion trauma, which is similar to post-traumatic stress disorder. The symptoms are wide ranging, including guilt, unresolved grief, flashbacks and, as Margaret said, anniversary triggers. In September each year, in the lead-up to the date of my abortion, and in April, when my son would have been born, I would feel sick. My son would be 27 years old —
I am sorry for getting upset, but it is an emotional subject.
The Chairperson:
That is understandable; take your time.
Mrs Coles:
I have been through a considerable healing process and, for 14 years, I have been involved in counselling men and women who are in the throes of post-abortion trauma.
Many women say — including, in the past, me — that they do not regret having had an abortion, because women get relief from the fact that an abortion has solved their problem. When a woman is in the midst of a crisis pregnancy, with pressure coming from those around her, she thinks that she must sort out the problem.
At the time of my pregnancy, I was in England, and the process was very quick. It was one week from the day of going for a pregnancy test until the day that was fixed for the abortion. I was told the usual story about a blob of cells; I was reminded that I had just started a new career, I had my whole life ahead of me and I had plenty of time to have children. I believed that. However, I did not know that, for 10 years, I would fixate on babies and look at friends’ children, wondering about my son walking, talking or starting school — those milestones live on. I failed to fully deal with my trauma.
Ten years after my first pregnancy, I miscarried, losing a daughter, Lily. I got pregnant again, and had my daughter Holly, who is now 18 years old. During that pregnancy, I was reading pregnancy books when I noticed that, in the first trimester, a baby has a heartbeat at eight weeks and is fully developed at 12 weeks. My son Stephen had been aborted at 10 weeks, which is the most common time for an abortion in the UK. That was when it hit me. Approximately three years later, I met somebody who spoke about post-abortion trauma and, eventually, the penny dropped for me, and I underwent a period of counselling.
For 14 years, in a voluntary capacity, I have been involved in helping men and women; initially as a befriender for the British abortion victims’ helpline, and then as a supervisor. Nowadays, my husband and I lead a post-abortion recovery ministry in our church called Choose Life, the aim of which is to reach out to people in our church community, our local community and beyond who are suffering from post-abortion trauma.
I should like to clarify some of the things that you might hear about this. I have raised this with the Department of Health. In response to Dr Deeny’s question, Stephen was not part of my body — he had separate DNA, the same as my two living children. Everything was there from the point of conception, but he was not my possession, nor was he part of my body, in the same way as my two living daughters are not physically attached to my body.
I had a safe and legal abortion, but it is not about the type of abortion that women have or the age of the baby when it is aborted — it is the abortion itself that damages us as women. Regardless of the circumstances surrounding an abortion — whether a woman is rich or poor or whether she has an abortion at 10 weeks or 40 weeks — it is the abortion itself that damages us as women.
The ability to afford an abortion does not make it right. Rich people have more access to cocaine, but that does not make it right. I am working class, and sometimes I think that abortion advocates want abortions for the working class more than the working class want or need abortions.
Having my abortion did not make me equal to my male colleagues, but I was encouraged to try to be their equal. I have worked in two male-dominated jobs. I worked as an equality officer for the Metropolitan Police, responsible for more than 500 women. Abortion does not give us equality. Abortion is a degrading, invasive procedure, which took the life of my son and left me physically, emotionally, psychologically and, more importantly, spiritually, damaged.
I want to focus on mental health, because the guidelines do not mention women who have had abortions in Northern Ireland. Organisations such as Life, the Choose Life Ministries and other voluntary organisations are picking up the aftermath of women who have gone to England to have abortions.
Mental health is a major issue. The mind has a strong coping mechanism, and denial can suppress the issue for many years, but it will surface in alcoholism, food addiction, drug addiction, self harming or suicide. I attempted suicide twice, and many of the women whom I counsel have also attempted suicide. It is a real, live issue. If the Department of Health is going to examine the guidelines seriously, it must consider the after-effects of abortion on women.
I have 3,000 sworn legal affidavits from the Justice Foundation in America, which have been used in the Supreme Court to testify to the detrimental effects of abortion. I will forward copies to the Committee, but, in the meantime, I will leave the covering letter with you today.
Dr Deeny:
I have a quick question regarding women’s mental health pre-termination, as it worries me as a doctor. There are a whole range of foetal abnormalities, and, as you said, we should not group them together. For instance, anencephaly is a very severe condition that is incompatible with life. Will doctors be expected to make a decision on the mental health of a mother? If so, that will put a lot of pressure on doctors, especially considering the legal implications, as Mrs Higgins mentioned, if we were to make the wrong call. There is not enough clarity and guidance on the mental-health issue. Paragraphs 2.4 and 2.5 of the guidance state that if a woman’s mental health is deemed to be seriously threatened, termination is lawful, but the medical practitioner is responsible for making that call. Paragraph 2.7 goes on to state that an assessment by two doctors is recommended. I am concerned about that.
Dr McDermott:
You are right. Some women with existing mental-health problems who have abortions then go on to develop more severe mental-health problems. Those people are vulnerable, and the last thing that anyone wants is for someone with a mental-health problem to end up with a more serious problem. Therefore, a practitioner who is experienced in treating depression should be involved in the process.
Getting rid of a baby will not solve any underlying mental-health problems. In fact, it will probably cause even worse problems. Therefore, we would like a consultant psychiatrist to be involved. The guidelines state that GPs and obstetricians should be involved, but that needs to be scrapped.
Mrs Higgins:
I am concerned that the interpretation of the law here implies that, for mental-health reasons, a woman can have an abortion up to full term. The guidelines clearly suggest that. If that is the case, then we have a worse situation in Northern Ireland than we have in England under the Abortion Act 1967. It is left for the doctor to decide whether someone has a mental-health problem such as depression. That absolutely blows the law apart. It is not true.
I have already explained that the child destruction exemption is very narrow: it does not apply to health and mental health. It really only relates to abortion that is carried out before 22 weeks. Even at that stage, the guidelines’ interpretation of the Bourne case is much too wide. It should only extend to what Judge Macnaghten termed “mental wrecks”. It is worth reading Macnaghten’s speech, because he also talked about the precious life of the child, the protection of which is why the law exists. The Bourne case has been taken apart and used to produce pro-abortion arguments. In fact, when the case is examined, it is much narrower than how it is portrayed; certainly, than how it is portrayed in those guidelines. The mental-health issue is of grave concern.
Mrs Coles:
I threatened to commit suicide in order to get the abortion. That is what women in England do. I agree that that is a loophole in the guidelines. A woman who threatens to commit suicide should be treated as a patient who is not pregnant. She should be treated and hospitalised. A Finnish study maintains that there is a 650% increase in the suicide rate among women who have had abortions compared with those who carried their babies to full term. Therefore, the risk of suicide after an abortion is an undeniable problem. How can a woman’s mental health be assessed during a brief appointment at which she is referred for an abortion?
The Chairperson:
Unfortunately, we have reached the end of the time that has been allocated for the session. I want to be fair to both sets of witnesses this morning. Thank you for your attendance. I am sure that you aware that the House of Commons is going to debate the Abortion Act 1967. I hope that wisdom will prevail in that debate.
Mrs Higgins:
Chairperson, I want to point out that we are volunteers. None of us is paid to do our work. We have come here as professionals who do that work voluntarily.
The Chairperson:
I appreciate that. Please leave all of your documentation with the Committee. That will be helpful.
The Chairperson:
The next evidence session is with pro-choice groups, and a copy of the submissions from them can be found in the members’ pack. I notice that the sound system is running now, which is rather welcome. On behalf of the Committee, I welcome Dr Audrey Simpson, the director of the Family Planning Association, Ms Georgie McCormick, training and services manager of the Family Planning Association, Grace Glenny, who is also from the Family Planning Association, and Pamela Dooley, the head of organisation and development at Unison.
The format for this meeting will be the same as it was with the previous set of witnesses. I will ask the witnesses to make a presentation, and we will allow members to ask questions and whoever wishes to answer can do so. This session is not restricted to just one person making a presentation or answering questions — you can spread the responses out among you. You are very welcome here today, and I will hand over to you now to make the presentation.
Dr Audrey Simpson (Family Planning Association):
Good morning — I can just about say that; it is very nearly afternoon.
The Chairperson:
We are still in morning mode.
Dr A Simpson:
First, Chairperson, I thank you for being clear about the reason for the meeting, which is to discuss the departmental guidelines and not the rights and wrongs of abortion. I am very happy to come back to the Committee to discuss that issue at another time, but I know that we are here today to discuss the guidelines.
First, can I be clear that none of us is members of the legal profession, nor are we doctors. If today’s meeting was to involve a debate about the law or medical issues, we would have brought along our lawyer or a doctor. We would also have brought along one of the many women in Northern Ireland who have had an abortion and who have been absolutely fine about it and have not experienced any emotional trauma. However, as we are here to deal with the guidelines, that is what we will discuss.
I will not say a lot about the guidelines, because I hope that you have read our response to them — I do not want to regurgitate the arguments that it contains. I should perhaps start by providing a little bit of background. The guidelines were the outcome of the Family Planning Association’s request for a judicial review of abortion law in Northern Ireland, so I will start by explaining why the organisation took the judicial review.
The review was taken as a result of our 20 years’ experience of working with women who face an unplanned or crisis pregnancy and with the health professionals who work with those women. It was very clear that there was unequal provision of abortion services in Northern Ireland, and that the service was often dictated by where one lived, who one knew and one’s postcode. Thus, there were clear inequalities in the provision of services. That was the basis of the judicial review: it was not — and I must emphasise this point — to liberalise the law. We received clarification of the law as a result of the review, which was good, and the fact sheet clearly refers to the law and what was stated in court. We work within the legal context; we are a voluntary organisation, and that is what we do.
Doctors still ring us — probably one GP a week — to ask what to do with a female patient in their surgery who is faced with an unplanned pregnancy. It seems a ludicrous situation that health professionals are ringing a voluntary organisation asking for advice about what to do with a patient. We hoped that the guidelines would give very clear pathways of referrals for health professionals working with women with an unplanned and crisis pregnancy. One of our criticisms of the guidelines is that the pathways of referrals are not very clear yet. Directors of clinical services of major hospitals in Northern Ireland have called us to ask what to do in a situation whereby they are dealing with a female patient who they think has grounds for an abortion in Northern Ireland, but all the staff are conscientious objectors. They have no idea what to do with the woman. Again, that is why the clear referral pathways are needed.
We have several problems with the guidelines, and the second major issue is the use of the term “counselling”. Georgie will talk about that from her experience as a counsellor.
Ms Georgie McCormick (Family Planning Association):
I have been involved in counselling and support agencies for 22 years. I contributed to the establishment of the National Association for the Childless, which supports men and women who have experienced fertility difficulties. I have also contributed to the establishment of support groups for women who have experienced miscarriage, post-natal depression, depression, and difficulties with hysterectomy, endometriosis and PMT. Therefore, I have had many years experience of working in women’s health.
As part of the development of those services to meet the reproductive health needs of women and men, I have contributed to the development of the unplanned pregnancy counselling service that the FPA currently controls. I have also been involved as a counsellor with Relate Northern Ireland for nine years; and in 1986 I was a founder member of the Nexus Institute.
In that time, I have worked with a wide range of women who, for a variety of reasons, have issues associated with fertility. I read the guidelines with two sets of eyes: first, as Audrey said, from the point of view of professionals who telephone us to ask what they are legally required to do and how they can offer genuine support to women; and from that of a witness, called today to represent thousands of women who are trying to find their way through systems.
When someone is in a crisis of any sort, trying to find a way through a system is terrifying and silencing. If we silence women, at any level, we are not providing them with any sort of forum to make good decisions; rather, we may contribute either to the continuation or to the termination of pregnancies.
For me, the outcome is not relevant with regard to morality or anything else; the morality is that we need systems that allow women transparent access to information, services and outcomes that are within the law and that look after them morally, socially, physically and mentally.
I have concentrated on those bits of the document that relate to counselling, which is dealt with from section 5 onwards, and I tie that into the issue of consent. I have worked not only as a counsellor, but as a trainer for 20 years. I have worked with Catholic Church organisations in the Republic and in the North of Ireland — and with Protestant Church organisations — and extensively throughout the UK, specifically, to clarify, from policy to practice, what is meant by “consent”, with a range of health professionals, including professionals from Muckamore Abbey Hospital, St John of God Hospital in the Republic and Camphill communities throughout the UK.
I tie those two aspects together because they are core elements in any process that will reach a decision. Unlike any other form of counselling, this has a decision at the end that is profound. No one debates how profound that decision is, and it never goes away. It never leaves a woman’s life. Part of post-abortion counselling is about integrating the experience into life. For the woman making the decision — and no other person — it becomes part of her life’s history. I will not go into all the therapeutic theories that inform the decision, unless the Committee has six hours.
With regard to the counselling issues, the language of the document refers constantly to “non-judgemental” and “non-directive” support and counselling, regardless of who provides it. That wording affects the ethics of the person, agency or organisation providing the counselling. It means that anyone involved in the practice of that needs to integrate it into their work. It also means that any information provided must be reputable, and based on sound research and approved by professional bodies. It must also contain no attitude that is directive or judgemental. Those three aspects, from ethics, policy and protocols, through to practice and information, must be inherent. Operating anything other than a three-option agency would be inherently judgemental and directive.
A three-option agency looks at carrying on with a pregnancy and becoming a parent. It does not end with a birth. It looks at a futurised world. It helps the woman look at her internal world and futurises that world for her. It is not just about having a baby, but about becoming a parent and looking at the infrastructure surrounding parenthood. It also looks at having a baby and giving that baby to someone else to parent — either through adoption or fostering.
The other option is to end a pregnancy with abortion, and all of the profoundness that that decision will have. Unless an agency or a person is looking at a three-option approach, with information to support each option, it could be argued that there would be consequences surrounding the issue of consent, which is referred to at paragraph 5.2 of the Department’s consultation document, which states clearly that there are legal requirements around assessing consent. We argue that unless all of those options are clearly balanced — and reputably balanced in the provision of service, the ethics around that service and the information that accompanies that service — it could impair a woman’s right to informed consent. That could have issues for the outcome, regardless of what that outcome may be, as well as for any professionals involved in the process.
As a witness for women trying to find their way through all of that, we need transparency, equality, language that is accessible and, if we are truly looking at a non-directive and a non-judgemental approach, we must support only those agencies that can give the three-option approach to pregnancy — regardless of whether it is a crisis pregnancy.
I have worked with women who had planned a pregnancy, and who were faced with a foetal abnormality and given 24 hours to make a decision: they were told on a Friday afternoon to be in the hospital on Monday morning. We must look at a practice that allows women good access and an informed decision that will support her in the future, so that she can incorporate whatever happens to her into her personal history.
Dr A Simpson:
I hope that that dispels the myth that the FPA encourages women to have abortions. Sometimes our counselling service sees parents storm out of the building because a counsellor will not talk their 15- or 16-year-old daughter into having an abortion, and that is why we are a three-option agency.
Another concern is aftercare. The judicial review in the Court of Appeal stated clearly that the Department had to take into account aftercare services. One of the major gaps in the guidance concerns the issue around women using Internet services, which members may have heard about recently. Desperate women do desperate things. There are rogue Internet sites. A recent ‘Spotlight’ programme highlighted the fact that some of the sites give incomplete prescriptions or placebos. The women have to fill in a questionnaire, and we know anecdotally that some of them have lied and said that they are further on in their pregnancy than they are, which has had severe health implications for those women.
The guidance must take into consideration what a doctor does when a women presents at accident and emergency with complications and admits that she has taken mifepristone. Does the doctor report that women to the police or not? What aftercare service is that women entitled to? Those questions have not been taken into account anywhere in the guidance. The use of Internet sites is a growing phenomenon in Northern Ireland because women just cannot afford to travel any more. As I said, desperate women do desperate things.
Last week, a woman telephoned the Family Planning Association, and when we told her that she could not have an abortion in Northern Ireland she said that she would get into her car and drive it into a wall. That is the reality of women faced with a crisis pregnancy.
The other issue that is missing from the guidance document, and which came out clearly in the investigation, was the lack of training for medical professionals. They have all said that they want training in the area, which is not provided for in the guidance document.
Ms Pamela Dooley (UNISON):
I welcome the fact that there will be guidance. I want to ensure that the guidance is clear, that it will be transparent, and that all women in Northern Ireland will have access to the guidance so that they have a complete understanding of what is and what is not available.
On the issue of equality, the guidance will address the matter of people who come from a background of money and people who come from a background of disadvantage. My experience has been that women who live in areas of social need in Northern Ireland have been at a disadvantage.
Part 4 of the Department’s consultation paper deals with conscientious objection. Although I have not come across a healthcare worker who has had a problem with that, the law still stands as it did in 1861. A person with a conscientious objection to terminating a pregnancy is unable to stand up and say so, and there could be employment issues. That must be sorted out.
I support Dr Simpson’s comments on the access to drugs on the Internet. In this day and age, every woman in Northern Ireland has such access. Some people do not have an understanding of the law and how it will affect them if they use those drugs. When people in that situation need medical care, they sometimes do not look for it because someone has told them what will happen if they seek it. Therefore, that person’s health is put at risk.
That issue must be addressed so that there are not women in Northern Ireland with health problems and the possibility that they will never be able to have a family during the rest of their lives. The guidance must be clear, and not subject to different interpretations by different professionals and different people. We have to know exactly what is out there, and every woman needs access to that.
Dr A Simpson:
We have gone over our allocated 10 minutes, so I will finish by saying that it is important to recognise that the guidance includes the fact that, as well as pregnancy counselling, we offer a post-abortion counselling service. Some women experience emotional trauma after having an abortion. Quite often, that is triggered by something else that has gone on in their life — for example, their partner leaving them. As the World Health Organization (WHO) says, there is no such thing as post-abortion trauma. It also says that abortion does not cause breast cancer. The guidance is clear that counselling agencies are not allowed to give out that information because it has been totally dismissed by the World Health Organization.
We are happy to take questions.
The Chairperson:
You mentioned that women were buying drugs on the Internet. What is the name of the drug that destroys the baby?
Dr A Simpson:
The brand name is RU486; it is also known as mifepristone. As you know, the Internet is very hard to control. One site, womenonweb.org, supplies the correct dosage. However, that does not mean that women will give the correct information, because desperate women will lie and take a double dose in the belief that that will cause an abortion. That can result in uterus problems and other health implications. Unless something is done, I am convinced that a woman will die.
Ms McCormick:
It is certainly the new backstreet abortion. Historically, when people talked about “backstreet abortions”, they usually meant seedy rooms and bad practice. However, in the twenty-first century, backstreet abortion means buying drugs on the Internet. Over the past few years, we have been monitoring the sites and several have, effectively, been closed down. To clarify what happens, RU486 can be taken at up to nine weeks of pregnancy and will cause a medical, but non-surgical, abortion.
The womenonweb.org site operates an assessment process that must be satisfactorily completed. However, women are often unsure of how far advanced their pregnancies are and may give inaccurate information. Unless a woman is clear about her dates and has the maturity, competence, capacity and support, she could be given the wrong information and receive drugs that are totally inappropriate.
Dr A Simpson:
We must remember that, since the Abortion Act 1967 became law in England, no known deaths have been caused by backstreet abortion, whereas there have been five in Northern Ireland. My mother is in her 80s and she was brought up in Sandy Row. She told me that she clearly remembered women lying in entries, as the back alleys in Sandy Row were called then, and they were haemorrhaging because they had had an illegal, unsafe abortion. All the international evidence shows that the only achievement of restrictive abortion law is to push women into unsafe abortion practices, and that is what happens today via the Internet.
The Chairperson:
Thank you for that clarification. The other point that interested me was that the World Health Organization does not recognise the trauma of abortion.
Dr A Simpson:
It recognises that some women may experience emotional upset.
The Chairperson:
It uses the word “may”.
Dr A Simpson:
It dismisses the notion of post-abortion trauma.
Ms McCormick:
It does not regard it as a clinical definition.
The Chairperson:
I am amazed that the World Health Organization does not recognise that. To lose a baby, never mind going through an abortion, causes trauma.
Ms McCormick:
It is not specific, because the trauma of miscarriage, stillbirth or losing a child, has implications. The World Health Organization does not recognise post-abortion syndrome as a clinical definition. Anyone who has sat in a room with women going though an abortion — and I have done so thousands of times — recognises that the process has an effect on her. Ultimately, however, the long-term and short-term impacts have been well researched, and the groups of women who may need more long-term support were identified as young girls of 13 or 14 years of age and women with children.
The Chairperson:
When I was here one day on business, an elderly lady approached me and told me that she had had an abortion 35 years previously and relived it every day. That is simply an example from my experience.
Ms McCormick:
I absolutely agree. I have worked with women’s groups for years, and women in their 70s tell me about their abortions. However, if you ask any woman how many children she has, she will list pregnancies and miscarriages, but will not talk openly about abortion. Therefore, the social stigma of abortion has an effect on mental health and well-being.
The World Health Organization considers the clinical definition, but there is no debate. It would be foolish for us to state that conception affects women’s lives and that when a woman conceives, her life will change. To deny that, however, would be equally foolish because conception changes women’s lives. There is evidence that post-natal depression has long-term clinical elements and that giving up children up for adoption has a long-term clinical effect on women. However, we are examining how conception changes women’s lives, and an environment must be created in which women can seek support to offer them a pathway to interpreting the event as part of their personal history. That is all that we seek from the guidelines.
The Chairperson:
I am just making the point, and I do not wish to labour it, that the Government denied the existence of post-traumatic stress disorder in the theatres of war and have now had to face the reality that it does exist.
Ms McCormick:
We are just saying that, at the moment, it is not seen as a clinical definition.
Mrs O’Neill:
Thank you for your presentation. I want to go back to your point about conscientious objection. Regarding the tight nature of the law at the moment, the cases where an abortion can occur are very rare. Is there a need for a section on conscientious objection? Surely a health worker would have to get involved only under exceptional or emergency circumstances. On the one hand, is there a need for that section? On the other hand, if there is, then it must be strengthened to protect the healthcare worker.
Ms Dooley:
If there is one case, then there is a need.
Mrs O’Neill:
On the other issue about the need for pathways to be detailed, the reason for the guidance is twofold: to clarify the matter for healthcare professionals; and also to provide clinical and good-practice guidelines. You are saying that that is still absent from the document.
Dr A Simpson:
The document does not even recognise that community family planning clinics are quite often the first point of contact that a woman with an unplanned pregnancy will have. There is no mention of community family planning clinics in the document.
Mr Easton:
Thank you for your presentation. I should just let you know that I am quite pro-life. I am not quite sure what I think about your presentation, but I had the impression from the media that you were pro-abortion. I am pleased to hear that that is not necessarily the case.
You spoke about the three-pronged approach. Do you not feel, with regard to counselling, that the initial approach in the case of a woman who has been diagnosed as being pregnant — and who may be panicking, not sure what she is going to do and thinking that the situation is a disaster — should be to tell her that she does not necessarily have to have an abortion, that she could work through how she would cope and that people are there to help her? Should that not be the main, first piece of advice given?
Ms McCormick:
I will give you some information on the structure of counselling. The first issue, the ethos of all counselling, is that the woman’s pregnancy and the woman herself are unique. That pregnancy is unique to her, so all of our counselling focuses on the woman, her pregnancy, and her future as she sees it. One of the first things that we look at is her support and her value system. Pregnancy is one of the biggest things that can impact on a woman, and some counselling theories direct that. Very often, even thinking about where she is or feeling bad about being pregnant takes her out of her own value system. It is absolutely core that her value and belief systems, her support network and her internal world are explored before any decision is taken.
The initial counselling is about the woman and her pregnancy, before any decision is made. The whole process is about the woman, her pregnancy and her world, and that must take up the bulk of the session. The decision she makes comes after that, so regardless of the routes that she wants to explore, the three options are then examined.
Mr Easton:
Do you find that that approach has successfully changed women’s minds about having an abortion?
Ms McCormick:
We are not in it to change women’s minds; we have to be non-judgemental and non-directive. It is inherent in our practice that any changing of women’s minds does not come from us. Some of that process has allowed women to make decisions, to be more informed either about what they want to do, or not do. However, very often the reality is that if a woman thinks she is pregnant, she is going to be thinking about it for quite a while before she even does a pregnancy test.
We have to unpick the internal process that the woman has gone through in order to allow her to get back to her initial consciousness, so that we can help her to experience more genuinely what has been happening to her. However, as practitioners and professional counsellors, and because of our standards of practice, we are not in any way allowed to influence that woman’s decision or attempt to change her mind.
Dr A Simpson:
Not all of the women who use the FPA’s counselling service decide to have an abortion. Some women just want the space to explore what is happening in their lives.
Ms McCormick:
Every woman has a chance to evaluate the service. The evaluation forms are freely available to the Committee to examine.
The Chairperson:
That would be helpful. Thank you.
Dr Deeny:
Thank you for your presentation. I am pleased to hear that the FPA offers three options; it is important to be aware of that.
There are many crises to deal with, not just in normal practice, but also in front-line healthcare. GPs can be called on to deal with incidents of domestic violence or potential suicide, and we now have crisis response teams. I hoped that you would say that, because the woman deems it to be a crisis, the option of having an abortion would be the last resort. Yes? I am delighted about that. I am thinking about the notion of a pregnancy being regarded as a crisis.
Many of the guidelines will have to be looked at again. Doctors are being presented with a dilemma. Let us face it, ladies. The counselling is so important, and there is reference to pre- and post-termination counselling, which is vital. The guidelines state that a woman must be enabled:
“to make an informed choice about termination or its alternatives.”
The document continues:
“The counsellor or psychotherapist will therefore need to be aware of the choices available including medical interventions, adoption services and support available for continuing with the pregnancy.”
The guidelines also state:
“All clinical assessments should be completed in a timely manner and without undue delay”.
Having seen the system work elsewhere, I know that that amounts to a 10-minute appointment with a GP and referral to a hospital. There is a sense that many of these processes are carried out quickly, which is a concern for many people. Do you agree that a certain period of time must be built into those processes? There is a contradiction between the need to guard against undue delay — that is, it must be done quickly —and the services that should be available pre-termination. Women must have access to counselling, but as a GP who believes in the sanctity of life, I think that we should support women more, and give them more counselling. They need more than a 10-minute consultation and a hospital referral. What are your views on the length of time that women need?
Ms McCormick:
We have struggled with that a lot. We do make emergency appointments available, but we support the notion that a woman needs time to integrate what is happening to her, to feel that she is pregnant and to look at any bonding that she has with the pregnancy. A woman needs time to internalise what is happening to her before she takes action, because that action, once taken, cannot be changed.
I have worked in several different areas of counselling, from sexual-abuse counselling to relationship counselling. This counselling has a decision at the end of it, and once the anaesthetic goes into that woman’s arm, she can no longer change what is happening to her. We know that. The internalisation of a woman’s pregnancy, the realisation that she is pregnant, and the processing of that information, is crucial. We have often struggled with giving women who contact us an appointment the following day. We have often thought that a woman needs a week. We ask her how long she has known that she is pregnant, and unpick that, and ask her how she responded to that news, in order to ascertain how prepared she is, mentally and emotionally, to start making a decision.
Our organisation has worked so long in this area that no one knows better than we do that that decision is taken at the very end of the process. Even if a woman gets on a plane, takes a taxi to the clinic and has a consultation there, she can still change her mind. We tell women all that.
The only point at which a woman cannot change her mind is when the anaesthetic has been administered. Even if she signs the consent form, she can still get up and walk out. We know that that decision is crucial to a woman’s well-being. That is a women’s health issue for us. Whether or not a woman goes on to be a parent, that decision is crucial to her health. I agree that there must be sufficient time.
Dr Deeny:
That does not happen across the water; that is why one in three women will have an abortion. It is done, basically, in a couple of days. It is done so quickly.
Dr A Simpson:
That is not strictly true, because in many areas there is a long waiting list. The woman must go to her GP, and the GP must to refer her to an NHS hospital, and then she has to wait for an appointment — unless she can suddenly turn up at a private abortion provider. Even then, she may have to wait for at least a week — perhaps two — for an appointment. We know that from the women whom we have counselled.
I will add a little bit to what Georgie said, as this is a good opportunity to dispel a lot of myths about our organisation. We do not provide an abortion-referral service. For example, if someone was to ring our organisation and ask for the telephone number of a clinic in England, we would not give it to them. That is not because we do not want to give such information out — it is freely available in the ‘Yellow Pages’ and on the Internet — but because we provide a counselling service.
Ms McCormick:
I wish to reiterate that we have worked with men, and we understand that men have a process of going through abortion and that it can impact on families. We are talking about women because women sign the consent form, but we absolutely understand the need to include men in the process of healing or dealing with the consequences of an unplanned pregnancy — we would like more money to enable us to do that.
Dr A Simpson:
At the beginning of the counselling, we always have a session alone with the woman. Even if a young girl comes in with her parents or her partner, we see her on her own to ensure that she is not being pressurised to have an abortion.
Mrs Hanna:
Good morning, ladies, you are very welcome. I want to ask you first about the hard-case scenarios. Roughly 200,000 abortions take place in GB each year; I suppose that that could be extrapolated to 5,000 to 6,000 cases here, if abortion was legalised here. Have you any idea how many of those cases could be described as hard-case scenarios — those which involve incest, rape or severe foetal abnormality? Those are the cases that are often cited. Do you have any figures on that? We assume that most of the babies that are aborted are healthy. It would be useful to have those figures.
Dr A Simpson:
In the fact sheet that we have provided, we have replicated the categories under which the Department releases the information. That information is not broken down into categories of foetal abnormality or mental health.
Mrs Hanna:
Or incest or rape?
Dr A Simpson:
No, none of that. If such data is available, we certainly have not seen it.
Mrs Hanna:
I have a few comments to make on your presentation. I totally agree that there is a need for independent counselling. In all areas of the Health Service there is a serious problem with lack of pathways and signposting; there is confusion in all areas, including cancer services and others, and people do not know who to speak to. You spoke about the three options: becoming a parent, adoption and abortion. As abortion is illegal in Northern Ireland, what is the legal dividing line between counselling and referring? I do not really understand that. If abortion is illegal here, what does counselling on abortion really involve?
On the issue of foetal abnormalities, Georgie, you spoke about women coming to you and saying that they had been told that they had until Monday to make up their minds. I understand that it is illegal here to abort on grounds of foetal abnormality.
Ms McCormick:
That is when a woman is offered an abortion for health reasons.
Mrs Hanna:
Is it health reasons, rather than foetal abnormality?
Dr A Simpson:
Abortion is legal.
Mrs Hanna:
It is legal in extreme cases.
Dr A Simpson:
It is not illegal, and, therefore, it is legal.
Mrs Hanna:
I understand that abortion is illegal here on grounds of foetal abnormality, except in extreme circumstances, such as when the mother’s life is in danger.
Dr A Simpson:
Abortion is legal in Northern Ireland if there is a grave and permanent risk to the woman’s mental or physical health. That grave and permanent risk must be probable rather than possible and must be a long-term risk — that is the Court of Appeal judgement. A woman who is diagnosed with foetal abnormality could argue that her mental health is at risk and that she could not cope with continuing the pregnancy. If a psychiatrist agrees with her, there may be grounds for an abortion. However, foetal abnormality on its own is not grounds for an abortion.
Mrs Hanna:
I did not understand that point, because I was tracking Georgie’s scenario, where the woman came to the clinic and said that she had until Monday to make a decision because she had a foetal abnormality.
You talked about a woman who threatened to drive into a wall. She certainly needed urgent care, but she needed urgent care, first and foremost, because she was threatening to commit suicide. I understand that a woman may face a crisis because she is expecting a baby and is concerned about the future, or because her marriage has broken down. However, the threatened suicide is the emergency.
If a woman obtains an abortifacient over the Internet, and if she experiences complications and attends an accident and emergency unit, I would hope and expect that she would be treated as an emergency regardless of the circumstances.
Ms McCormick:
Doctors have told us that they are unsure where they stand under their own professional guidelines. They have not received training on the usage of such drugs or on the aftercare of women who have taken them.
Mrs Hanna:
If a woman is haemorrhaging, she must be treated urgently.
Dr A Simpson:
A woman who seeks medical attention may be concerned that she will be reported to PSNI.
Mrs Hanna:
So that is the issue.
Ms McCormick:
According to the theory of the law, she could face penal servitude.
Mrs Hanna:
I misunderstood; I thought that Dr Simpson said that doctors are unsure whether they could treat women in those circumstances.
Ms McCormick:
On occasion, a woman might phone the helpline and say that she bought drugs on the Internet and does not know what to do. In that event, I would ask several doctors whether we could refer the woman to them, because we are not medical practitioners. Some doctors may view the situation as a serious crime and might report the woman under the Criminal Justice Act ( Northern Ireland) 1945. Other doctors say that they are not trained in the aftercare of the drug and, therefore, are unsure where they stand, professionally, if they provide aftercare. If I am in the office speaking to a woman on the phone, what am I supposed to tell her?
Mrs Hanna:
Is the woman ill? That is what I do not understand.
Ms McCormick:
I am not qualified to determine whether she is ill.
Mrs Hanna:
I thought that you said that she is.
Ms McCormick:
No, I must refer her to someone who can determine whether she is ill. I cannot make that judgement, because I have no medical training.
Mrs Hanna:
That is fine; I thought that she was ill and needed attention.
Ms McCormick:
Although the woman may claim to be ill, I cannot judge whether she needs attention. I need to refer her to someone who can make that decision. When a woman is on the phone and says that she feels ill or that she is worried about infection or is panicking, I cannot make that decision.
Dr A Simpson:
Why does the guidance not address the training issue? Training must be available for doctors, because they do not use abortifacients, whereas doctors in England have that experience.
Mrs Hanna:
Are doctors in England trained?
Dr A Simpson:
Yes, they are trained.
The Chairperson:
It is serious problem that such drugs are available on the Internet. By that logic, any woman can obtain the drug, abort her pregnancy and, subsequently, attend hospital. It flies in the face of the guidance for legal abortion in Northern Ireland. Obviously, something must be done about the availability of those drugs on the Internet.
Mr Buchanan:
I agree that the guidelines must be clear-cut for the mother, the medical profession and everyone; there can be no grey areas or ambiguities. Your presentation caused me some concern. It, rightly, focused on the mother and whether the mother wants an abortion and the regulations pertaining to that. However, the presentation focused very little on the child and the rights of the child.
Let us remember that, from conception, a child is a living being in his or her mother’s womb. I did not hear you say much about what should be included in the guidelines to protect that living being — the living person in the womb. I agree that we need to focus on the mother, if she has a difficulty or a problem, but we must focus as much, if not more, on the unborn child, because he or she does not have a voice and cannot speak for himself or herself until much later.
I will nail my colours to the mast by saying that abortion — the taking of the life of an unborn child — cannot be classed as anything other than murder. That is how I view the issue. If someone takes a life, irrespective of whether it is through abortion or in any other sphere, it should be classed as murder. What is your position on the protection of the unborn child? Which guidelines fail to protect the unborn child?
What percentage of women who visit the FPA to seek counselling or to find out about having an abortion go on to have an abortion? That is the point at which counselling will be effective for women who are considering abortion. The guidance must be clear about the counselling that is given to a woman who seeks an abortion. Counselling should be considered effective if, after it, a woman who was considering having an abortion changes her mind and continues with the pregnancy until birth.
Dr A Simpson:
First, it is very unfortunate that Mr Buchanan used the term “murder”. In so doing, he is saying that a woman who has an abortion is doing something illegal. Women who have abortions are not doing something that is illegal. “Murder” is a very emotive term. I had hoped that we would have had this discussion today without using such emotive terms. The term stigmatises women. We have said that some women experience emotional trauma because they are stigmatised by people who use terms, such as “murder”, to describe abortion. It is very unfortunate that we cannot have this discussion without people using such emotive language.
The Chairperson:
I must intervene. The member is entitled to express an opinion.
Dr A Simpson:
Mrs Robinson, I am just saying that it is unfortunate that the term was used. I thought that we were having a really good and informed discussion, but it is unfortunate that that term was used.
The Chairperson:
It is not up to us to disallow anyone to express a sincerely held view. That is why we are having this debate. Of course, the term is emotive, but, at the same time, it is not up to you or me, as Chairperson, to say that someone cannot express a view.
Dr A Simpson:
I am not saying that he cannot his express his view, but it is unfortunate that he used that term.
Ms McCormick:
I will use your language and the term “the unborn child” when responding to your question. Realistically, the only connection that we have with the unborn foetus, or child, is through the woman, because we cannot communicate directly with the unborn child, and say: “Do you want to be born?” Therefore, we cannot treat the unborn child as an entity in relation to counselling, and I am talking only about counselling.
There is nothing else that we, as professional counsellors, can do other than work with the woman, because she is the person presenting with the need for counselling. We enable the woman to explore how she views her pregnancy and whether she is connected to, or bonding with, her pregnancy. On many occasions, if the woman has displayed strong bonds with the foetus in the way in which she has viewed her pregnancy, and if she has called it a child, I have said, “You have talked repeatedly about your pregnancy as a child. Do you want to talk to me about that and about how you view the child or how you view a future?”
With regard to professional standards, I must work with the woman who is in the room. I cannot communicate independently with the foetus, but I can communicate — and we do it thoroughly — through the woman. Furthermore, as far as professional standards are concerned, as a practising counsellor, I cannot influence the woman’s decision in any way, regardless of what that decision might be. I would no longer be able to practise as a counsellor if I did that.
Dr A Simpson:
Our counselling service is not about changing the woman’s mind but about getting her to a place where she can make her own decision.
Ms McCormick:
I wish to nail our colours to the mast: women across the world routinely cross water, break laws, self harm and are proactive in ending pregnancies. Historically, they always have done so. Personally and professionally, I will walk every inch of the way with those women regardless. I have always done so, and I always will, because they should not be left on their own at such a time.
Dr Deeny:
That is the crux of the matter: as doctors, we always treat mother and baby as two patients. For example, in the first trimester, we make sure that mothers are not x-rayed, and we check their drugs, because we are thinking of the baby too. You said that your agency does not treat them as two patients.
Ms McCormick:
We are counselling practitioners.
Dr Deeny:
Do you treat the pregnant mother and her unborn baby as two patients — two people?
Dr A Simpson:
We treat the woman as our client, and her pregnancy —
Dr Deeny:
I do not like the word “client”. They are patients.
Dr A Simpson:
No, they are not patients. We are not —
Dr Deeny:
I have 8,200 patients, and most of them are not sick. “Clients” is a new term in the past 10 years.
Ms McCormick:
In professional counselling, the term is “clients”; it is not “patients”.
Dr Deeny:
Well, that is your choice. We call them patients.
Ms McCormick:
No, it is not my choice. According to British Association for Counselling and Psychotherapy standards, the preferred term is “clients”. That is our professional counselling body, in the same way as you have —
Dr Deeny:
Getting back to the question: do you treat them as two individual entities?
Ms McCormick:
No, the woman is our client.
The Chairperson:
Therefore, in all the discussions that we have had, the baby does not come into the equation?
Ms McCormick:
Only in as much as it is part of the woman’s world. The relationship between the woman and her pregnancy is unique.
The Chairperson:
Do you, therefore, not bring any moral view to the situation?
Ms McCormick:
As professional counsellors, our personal morality should not be in the room. The ethical standards of counselling ask for a non-judgemental, non-directive approach, as do the Department’s guidelines. In addition, the Department’s research document on counselling repeatedly uses the terms “non-judgemental” and “non-directive”, which are the core conditions of any professional counselling.
The Chairperson:
I, too, will nail my colours to the mast. What about the rights of the unborn child, who is voiceless in all of this?
Ms McCormick:
We campaign actively for the rights of born children —
The Chairperson:
Sorry?
Ms McCormick:
Children who are in the world, many of whom are left abused, untreated, unwanted, uncared for and not provided for in the Northern Ireland healthcare system.
In the FPA’s work around unplanned pregnancy, the woman is the client.
Dr A Simpson:
There is a myth that, if a woman who has an unplanned pregnancy continues with the pregnancy, everything will be great. Not all unplanned pregnancies end up being unwanted; people who come to our service might decide not to have an abortion. However, the myth is that the woman who continues with her unplanned pregnancy will be fine about the baby and will love it. If that is the case, why are there so many children who are sexually, physically and emotionally abused, abandoned, and put in care?
Ms McCormick:
They are advertised on television and on buses as being available for adoption and fostering. We advertise live children on buses and on television.
The Chairperson:
Yes, but the conclusion is that those children are alive and will get a home and love, hopefully.
Ms McCormick:
Yes, but that is an ideal.
The Chairperson:
No, it is not; that is an outcome that happens.
Ms McCormick:
No, it is not an outcome.
The Chairperson:
I am sorry, but I disagree with you.
Ms McCormick:
It is an ideal. There are many, many children in the care system who would not agree with what you have just said.
The Chairperson:
Yes, but they are loved in the care system —
Ms McCormick:
There are a lot of people —
The Chairperson:
— and they are protected. Excuse me, I am speaking, and I am the Chairperson. They are protected in the care system, and they are not abused in the care system — usually.
Ms McCormick:
Usually; but we know that there have been instances of children being abused in the care system.
The Chairperson:
Yes, but that happens right across the board. That is human nature; there will always be those who pose a danger to children. Our laws are very lax in dealing with people who abuse children, and those laws must be examined. I am saying that any child in care is normally protected, living, breathing, eating and sleeping, and is loved to a point, and, hopefully, a home will be found for him or her. That is an outcome; those children are alive, and, hopefully, they will go on to live good lives. However, when a child is dead, a child is dead. Nothing can happen to it any more, it is dead.
Mrs Hanna:
The Family Planning Association seems to be saying that the rationale for dealing only with the mother and not the child is that there are so many neglected children in the Health Service — which I hope and believe is not the case. Is that right? Is the reason why you focus on the mother, rather than the mother and the child, because there are so many poor, unwanted and neglected children up for adoption — and, indeed, poor children in the Third World, or whatever? That seemed to be the rationale that you gave for not focusing on the child.
Ms McCormick:
The rationale for not focusing on a child in a counselling session is —
Mrs Hanna:
I am talking about what you just said.
Ms McCormick:
The morality?
Mrs Hanna:
Whatever you just said. You said that the organisation focuses on the mother because the advertisements on the buses show so many unwanted and neglected children. It seemed almost to be a rationale for focusing only on the mother.
Ms McCormick:
I said that we focused on the mother in unplanned pregnancies and that, in other areas of our work, we concern ourselves with the well-being of existing children.
Mrs Hanna:
It was just that you used that as the rationale for focusing on the mother.
Ms McCormick:
The rationale for focusing on the woman in the counselling room is that she is our client, and the only way in which we can determine anything about the pregnancy is through her. As a counsellor, I cannot work with a foetus.
The Chairperson:
Georgie, with the greatest of respect, I felt that you almost excused people going down the route of abortion because a child could appear on the side of a bus in an adoption advertisement.
Ms McCormick:
Very often, a woman’s decision for not wanting to carry on with a pregnancy is that she does not feel that she could be a responsible parent. For us, responsible parenting is core to any child’s well-being and health.
Mr Buchanan:
There are other options. Adoption and fostering have been mentioned, and I have seen them work. My sister is adopted, and she is just as much my sister — more perhaps — as she would be if she was my natural sister.
The Chairperson:
She was chosen.
Mr Buchanan:
That wee girl was adopted when she was six weeks old. If that mother had decided that she did not want that child or that she could not have it, and had she decided to just go and have an abortion, that child would not have a life or a voice of her own. Yet, today, I can relate to that person as my sister.
I was gravely concerned to hear you talk of people as clients — you are classing them as being only a number in society. You say that they are not patients. That does not refer to them as a caring human being. Let us remember that, once a woman becomes pregnant and has a child forming inside her, she has a duty of care to that child in her womb. To refer to her as a client or as a number, and to not take into consideration in the counselling process that another living being is present — albeit one who has no voice at the time — is very alarming, to say the least.
Dr A Simpson:
As I said earlier, our counselling is evaluated. We offer clients an evaluating service, and I am happy to make evaluations available to the Committee. They will show clearly that we do not treat people as numbers.
With respect to the Chairperson, this meeting is degenerating into a situation where the FPA must defend itself, and it is going into the rights and wrongs of abortion. I agreed to come here today to discuss the guidance document. If I could stress —
The Chairperson:
May I interrupt you? In fairness, Audrey, everyone touched on everything but that, and you all used the opportunity to express your own particular points of view that did not exactly relate to the format of the Department’s guidelines.
We all enjoyed more than a little leniency and flexibility in that respect.
Dr A Simpson:
Anyway, no one has talked about the issue of how we prevent women from becoming pregnant. The counselling service is only a small part of the FPA’s service, as we appear to be focusing on it as an organisation. The vast majority of our work involves helping people — particularly young women — to make good decisions about their personal and sexual lives, so that they do not find themselves in that position. We work with young men and women, parents, and people with learning disabilities so that they can enjoy sexual health and do not find themselves facing an unplanned or crisis pregnancy. That is crucial.
Ms Dooley:
I have been listening to this discussion for the past 15 minutes or half an hour. I support the FPA because I was that sixteen-year-old child who had a baby. I was very lucky that I had responsible parents and people who loved me and who cared for me and for my child. I could have been something and someone very different. I was directed towards the FPA by my doctor — not by my parents — and, because of that, I have had a life, and my daughter has had a life. I have been able to not be disadvantaged; to not be one of the one-in-four children in Belfast who leaves school without an education; and to not be one of the one-in-three people who do not get the right food. You are running down an organisation that makes such a difference to the lives of disadvantaged people in Northern Ireland.
The Chairperson:
In fairness, Pamela, I do not think anyone has run down the organisation. I hope that everyone has had an opportunity to express sincerely held views: they have a right to do so. If we disagree, we have a right to do so.
Ms Dooley:
That is why I have expressed my view.
The Chairperson:
Yes, and I have given you the opportunity to express your view, just as I have given my colleagues the opportunity to express theirs.
Our time is up. We have given the same length of time to both organisations. I thank the witnesses for attending.
On behalf of the Committee, I welcome the Chief Medical Officer, Michael McBride; senior medical officer Margaret Boyle; Oswyn Paulin, head of legal services at the Departmental Solicitor’s Office; Sean Holland, assistant chief social services officer; and Martin Bradley, chief nursing officer.
The Committee heard evidence from pro-choice and pro-life representatives this morning. You are welcome. I invite you to make a short presentation after which approximately one hour will be allowed for discussion.
Dr Michael McBride (Department of Health, Social Services and Public Safety):
Thank you, Chairperson and members. Today is an important opportunity for us to hear the Committee’s views. I know that many members have a keen interest in the subject. I hope that this meeting will provide us with an opportunity to answer queries in relation to the guidance on abortion.
The law on the termination of pregnancy in Northern Ireland is set out in the Offences Against the Person Act 1861; the Criminal Justice Act ( Northern Ireland) 1945, and in case law.
The Department cannot alter the law: that would require legislation. At present, the criminal law that governs the circumstances in which termination of pregnancy can occur in Northern Ireland is a reserved matter. Likewise, it is important to note that it is the role of the courts to authoritatively interpret and apply that law.
The purpose of the Department’s guidelines is to explain the law and to advise on how it relates to best practice. The guidelines also provide guidance on referral procedures, the giving of informed consent, the provision of aftercare services and the right of conscientious objection.
In Northern Ireland, termination of pregnancy is allowed only when there is a threat to the life of the mother or the risk of a real and serious adverse long-term or permanent affect on her health. Many people in this room have strong opinions on the current law in Northern Ireland, and I know that the views of other groups interested in the guidance have been heard this morning. In spite of the fact that many people may believe that the law in Northern Ireland should be changed, this guidance does not alter the law, and the Department has no power to so do.
This is a consultation process during which, as was pointed out in evidence, the word “only” has been omitted from paragraphs 2.2(i) and 2.6 of the guidance. Paragraph 2.4 did include the word “only”, and I recognise that, in order to ensure consistency and that the guidance is not misinterpreted, section 25(1) of the Criminal Justice Act ( Northern Ireland) 1945 must be accurately quoted and referenced. As a result of feedback during consultation, I have requested that section 25(2) of the Criminal Justice Act ( Northern Ireland) 1945 should also be included in the guidance.
At this point, I emphasise that the Committee has asked us — as departmental officials — to discuss issues raised by the guidance. I am aware that many members and the groups that gave evidence this morning are interested in the Human Fertilisation and Embryology Bill, which some parties hope to use as a means to extend the remit of the Abortion Act 1967 to Northern Ireland. That is not a matter on which we can comment.
Improving the sexual health of our population, and that of young people, in particular, is a key priority. During the past six years, the number of births to mothers aged 19 and under has fallen by 18%. There has also been a reduction of 27% in the number of mothers under the age of 17. The new sexual health strategy and action plan that the Committee commented on and supported in May, includes targets to increase the number of young people delaying sexual activity and reduce the rates of births to teenage mothers. That strategy is awaiting Executive approval. I know that we all want to see it published soon.
I will take a few minutes to advise the Committee of the background to the guidance document. On 4 October 2004, the Court of Appeal ruled that healthcare professionals in Northern Ireland were uncertain about when termination of pregnancy was legal in Northern Ireland. The Court of Appeal ordered that the Department consider what steps it should take in order to:
“Inquire into the adequacy of termination of pregnancy services provided in Northern Ireland (including aftercare); and following such inquiry, and after appropriate consultation with concerned organisations, issue appropriate guidance. ”
The Department set up a co-ordinating group chaired by the previous Chief Medical Officer to oversee its response to the court’s decision. Workshops were held, and a questionnaire was sent to healthcare professionals and to the chief executives of trusts. The almost 2,500 responses received were used to help develop the guidance. Expert input from a range of healthcare professionals was sought during the development of the initial guidance, and, in January 2007, the Department issued the draft guidance to interested parties for comment. The consultation closed on 20 April 2007 before the restoration of devolution.
A series of meetings was held with interested groups that included: the Society for the Protection of Unborn Children; Life Northern Ireland; Doctors for Life; Northern Catholic Bishops; Silent No More; Precious Life, and the Family Planning Association of Northern Ireland.
In October 2007, the Minister announced that a new group would be established, under my chairmanship, to revise the guidelines taking into account the responses received during the consultation on the draft guidance. On 16 July 2008, the group issued the current version of the guidelines for consultation, the closing date for which was 22 September 2008, and 53 responses were received. From the responses that we received from health professionals, the urgent need for the guidelines was clear.
Today’s meeting provides an important opportunity for us to listen to the views of the Committee’s members. As I stated earlier, the guidelines simply explain the law as it stands in Northern Ireland. They do not, and cannot, change the law, or alter the way in which the law is interpreted by the courts. My colleagues and I are happy to answer any of the Committee’s questions on the guidance document.
The Chairperson:
Thank you, Michael. You quickly indicated changes at 2.2(i), 2.6 and 2.4. Will you briefly take me through those again, so that I am clear that you are amending those paragraphs? Is that what you were saying?
Dr McBride:
Yes. I was pointing out that during the consultation, and as was said in evidence this morning, the word “only” had been omitted from paragraphs 2.2(i) and 2.6 of the guidance. The word “only” has been included in paragraph 2.4 but was omitted from the other two. It was a simple omission from the document. To ensure the consistency of interpretation, we will insert the word “only” into the aforementioned paragraphs 2.2(i) and 2.6.
Mrs O’Neill:
Thank you for attending today. Michael, you said that the guidelines are intended simply to explain and clarify the law. However, this morning during both presentations the Committee heard that people feel that it remains unclear. Particular concerns are that the pathways to referrals for healthcare workers are not clearly set out and that there is a lack of clarity for doctors about conscientious objection. Both presentations this morning mentioned that, and that the guidelines are not serving their intended purpose.
During this morning’s evidence session, Internet sites from which women can access drugs were also mentioned. Beyond the guidance being discussed today, is the Department pursuing that matter and considering whether it can act? I have a further question, which is about aftercare, but I will return to that.
Dr McBride:
I will start with the issue of conscientious objection. As members are aware, the Abortion Act 1967 does not extend to Northern Ireland, and there are no plans to change that. Therefore, it is important to note that the legal protection afforded by the 1967 Act does not apply here. The draft guidance is clear, however, that no one can compel staff to participate in a termination. It states that staff have a right to object on the grounds of conscience and that when they do so, that right should be recognised and respected — except in circumstances in which the woman’s life is in immediate danger and emergency action is required.
The guidance document clearly states that health and social care trusts should have appropriate arrangements in place to accommodate such requests from staff. I listened to parts of the evidence sessions that took place this morning. Staff with conscientious objection should not opt out of providing routine, general care for women undergoing a termination of pregnancy. BMA documentation recognises that doctors have an ethical responsibility to provide general care for women who are undergoing a termination of pregnancy. The guidance document also refers to GMC and Nursing and Midwifery Council guidance on conscientious objection.
Like other members of society, doctors and other healthcare professionals have religious and moral beliefs. However, where those beliefs potentially conflict with the treatment or advice that one is providing to patients in one’s care then, as a doctor, one has a professional responsibility to determine whether that advice would be influenced by those beliefs. If there is a potential conflict, the doctor or other healthcare professional has an obligation to inform the patient accordingly and ensure that that patient is given the opportunity to discuss their situation with a professional who feels better placed to give advice. A woman must to able to make an informed decision. Consent to a termination of pregnancy must be fully informed by consideration of all of the options available to the individual, and that information must be provided impartially.
The referral pathways that were mentioned are beyond the scope of the guidance document. I anticipate that significant work — not associated with the development of guidance — will be required following the finalisation of the guidance.
It is vitally important to be aware that — although it is illegal to procure an unlawful termination of pregnancy — it is not illegal for a woman to purchase drugs on the Internet. Mr Paulin may want to comment further on the legal position. All healthcare professionals are aware of the dangers of patients accessing unregulated drugs or taking drugs about which they have not received expert advice.
Drugs that are available on the Internet are unregulated and, therefore, there are significant issues concerning their quality and safety. Indeed, many of the drugs may be counterfeit. The Medicine and Healthcare Products Regulatory Agency and the Department’s enforcement branch equip us with robust measures, but doctors and other healthcare professionals must make a professional judgement about the advice that they give to women. That advice should be provided in the knowledge that the use of drugs that have been purchased on the Internet carries inherent dangers.
Every woman is entitled to the appropriate aftercare following a termination, irrespective of where she presents, the nature of her complications or where the termination was carried out. In addition to medical care, every woman is entitled to the necessary counselling and support services; as are other family members who may have been affected by a termination of pregnancy. I hope that I have covered all points.
Mrs O’Neill:
Yes, you did. I have concerns about the term “appropriate arrangements”, where it says that:
“Health and Social Care Trusts should also have appropriate arrangements in place to accommodate such requests from staff.”
There is always great disparity between what happens in one trust and what happens in another. I am concerned that there is no uniform approach to deal with the issue.
Dr McBride:
You make a valid point: I will ask Martin to speak on that matter. Clearly, there are limits on what a guidance document can state, because it must comply with the Court of Appeal’s order on the provision of guidance. In the development of the guidance, we identified several issues that require further action. One relates to care pathways, which you mentioned: the other relates to arrangements to facilitate staff with conscientious objections. Clearly, it is important that staff raise their conscientious objections as early as possible in order to allow the trust’s management make alternative arrangements. Martin will talk about arrangements for conscientious objection.
Mr Martin Bradley (Department of Health, Social Services and Public Safety):
We have discussed the matter with the trade unions and staff side. We are minded to produce a circular on it in the context of the guidance. As you know, the Abortion Act 1967 does not apply in Northern Ireland. The legislation that was introduced in England to cover conscientious objection also does not exist in Northern Ireland. A clear statement is needed — such as that which the guidance puts out — advising that employers in health and social care in Northern Ireland will have a standard that acknowledges and recognises that people will have conscientious objections, and that those must be respected. That applies not only to doctors and nurses, but also to ancillary staff — porters, for example. The issue of disposal of foetal tissue was raised. If a porter has a conscientious objection to the termination of pregnancy, it would be perverse to expect that person to be involved in the disposal of foetal tissue.
Therefore, we must be clear that there is an expectation that conscientious objection would be respected. However, as Michael has already said, there is also an overarching duty that care is provided to everyone who requires it, regardless of the circumstances. We are in the business of protecting life and safeguarding the well-being of all women. Therefore, there would be times when a professional body will have an expectation that, even if someone has a conscientious objection, they must follow the ethical code and provide care in an emergency and when a woman’s life is in danger.
Mr Easton:
The guidelines refer to circumstances in which the termination of pregnancy is illegal when a foetus is deformed. Is abortion illegal on those grounds?
Dr McBride:
It is illegal when foetal abnormality is the sole reason for termination of pregnancy. It is illegal unless other circumstances apply; for example, when there is foetal abnormality and the mother’s life is in danger and there are serious long-term, or permanent, risks to her health. The guidance is specific that foetal abnormality on its own is not grounds for lawful termination of pregnancy in Northern Ireland. That is correct.
Mr Easton:
The first team of witnesses today suggested that that is a grey area and that, perhaps, some abortions on those grounds might happen. Are the guidelines robust enough to ensure that that is not the case? I am not saying that that happens. However, it has been suggested that it might be the case.
Mr Oswyn Paulin (Departmental Solicitor’s Office):
Paragraph 2.4 of the guidance states that:
“Fetal abnormality is not recognised as grounds for termination of pregnancy in Northern Ireland”.
That is quite definitive.
Mr Easton:
It seems to be. However, it has been suggested that there are ways round that. That is my first concern.
Dr McBride:
As regards the phrase “ways round that”, the law is very clear on the matter. Oswyn will highlight the severe punitive impact that the law might have in relation to such matters.
Mr Paulin:
The offences are set out in the Offences Against the Person Act 1861and the Criminal Justice Act ( Northern Ireland) 1945. Heavy penalties are available to the courts for offences in which unlawful termination of pregnancy occurs. It is a fairly unusual charge, but there was a reported case in 1999 in which a child was killed in its mother’s womb without the consent of the mother. A very hefty penalty was imposed on the person who did that.
Mr Easton:
If someone goes to their GP for advice about abortion, does that GP have the right not to give that advice under the grounds of conscientious objection?
Dr McBride:
Further to my earlier point; under good medical practice, doctors must, at all times, act in the best interests of their patients. As Martin highlighted, and as I said about the GMC’s position on the matter:
“If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor.”
The doctor has a responsibility to make that clear to the patient and to refer them to someone who is in a position to give fully informed advice regarding the termination of a pregnancy, and advice, within the framework of the law in Northern Ireland.
Mr Easton:
That brings me to my main point. If a GP is prepared to discuss the matter and to give advice on it, is it legal for a GP in Northern Ireland to refer someone to England for an abortion?
Mr Paulin:
We have taken the view that the guidance is in relation to the Health Service in Northern Ireland and services that are provided in Northern Ireland: not in relation to the legality of services provided elsewhere. However, it would be odd if a doctor could assist in providing a service that was not lawful in Northern Ireland. It is a criminal offence to provide an unlawful termination of pregnancy in Northern Ireland. Therefore, it is difficult to see how that can be done through medical practice here.
Mr Easton:
Can a doctor here write a note to refer a patient to services in England?
Mr Paulin:
Healthcare professionals should only refer women to services that are lawfully available in Northern Ireland.
Mr Easton:
Would it be illegal to refer a patient to England?
The Chairperson:
The member wishes to clarify that it is outside the law for a GP to recommend a procedure in England.
Dr McBride:
No such arrangement exists for a patient to be referred to another doctor in England. Indeed, any healthcare professional practising in Northern Ireland must practice within the professional codes of conduct of the specific regulatory body and within the law as it stands in Northern Ireland. Therefore, as Oswyn has indicated, it would be perverse for a doctor to refer a woman, in the manner that has been suggested, for a termination that is not within the law — in other words, that is not legal in Northern Ireland.
Mr Easton:
Finally, I wish to ask about the counselling set-up. A woman who goes to see her GP for advice about an abortion can be referred for counselling. Does that take the form of pro-life counselling or will all options be suggested? I want to see guidelines that are totally pro-life and that make every effort to maintain the life of the unborn foetus. Every available chance should be given to that woman to ensure that she is given support so that she does not have to have an abortion. I believe firmly that, from the beginning, any advice given should be pretty darned pro-life.
Dr McBride:
My other colleagues may also want to answer that question. I respect your views on counselling and your personal views that the advice should be directed towards pro-life. However, counselling services provided by health and social-care organisations must be non-directional and non-judgemental. The guidance goes on to state that trusts should be satisfied that competent and appropriately trained personnel will provide that counselling.
We all have views, and many of us have very strongly held views. This is about ensuring that women who, within the law in Northern Ireland, consider their options and are in a position to make a fully informed decision. Therefore, that means that they should be made aware of all the options available to them within the law in Northern Ireland.
Mr Sean Holland (Department of Health, Social Services and Public Safety):
We recognise that a wide variety of directional counselling is available. However, where counselling is being provided by health and social-care organisations, or on behalf of health and social-care organisations, it should be non-judgemental and non-directional. If a woman has gone to a GP, or to another medical practitioner, and has been assessed as meeting the legal criteria for having an abortion in Northern Ireland, and she wishes to seek counselling on how to follow that course of treatment, it is important in those circumstances that she receive non-judgemental counselling.
The Chairperson:
Surely if it is illegal — other than the stipulated guidelines — it would be logical to assume that, for the welfare of that unborn child, the counselling would take a pro-life direction. A woman can have an abortion only if it meets those two aspects of the law as it stands in Northern Ireland. Therefore, everyone else should be guided in the direction of saving the unborn child, because to advise anything else would be illegal.
Dr McBride:
The important point is that all considerations around the termination of a pregnancy, and all those discussions, must fall within the legal framework of Northern Ireland. The counselling provided must be within that legal framework as well. However, it must be non-judgemental and non-directional. A woman may decide to continue with a pregnancy, despite the best advice that she has been given on the fact that there is a real and serious significant threat to her life, or that there is likely to be a long-term or permanent threat to her health. That is her choice to make.
The process must ensure that each and every woman in that situation arrives at a point at which she can make a fully informed decision, having weighed up the relative pros and cons of all the options available to her. Sean may wish to add to what I have said.
Mr Holland:
I would have made the same point, Michael. It is conceivable to have a situation in which a woman has been advised by a medical practitioner that an abortion would be in her best interests. That woman would not take such a decision lightly, but it is not always the case that she will automatically follow the advice given. I am sure that, in those circumstances, many women opt for a period of reflection and consideration. As part of that process, a woman may seek counselling, and if that counselling is provided by, or on behalf of, a health and social-care organisation, we must recognise that a woman has a number of choices available to her. Given that situation, the counselling should be non-directional and non-judgemental.
The Chairperson:
I am finding this difficult to follow. Please bear with me: I do not have a legal background, but I do have a very strong moral view. If the two circumstances in which abortion is permitted are set aside, and the woman does not fit into either category, how can she possibly be told about the abortion option? I am trying to understand that. How do you give advice on all the options, one of which is abortion, when to do so would be illegal, because the woman did not fit into either of the two categories that would direct her towards having an abortion?
Dr McBride:
In those circumstances, one would not advise a woman that termination of her pregnancy is an option within the legal framework in Northern Ireland. You are quite correct.
The Chairperson:
Why is that not made very clear? You are talking about a woman’s right to have all her options explained to her in a non-judgemental fashion. How can that include the abortion option?
Dr McBride:
I will ask Martin to come in —
The Chairperson:
I am just trying to clear this matter up, because it is important.
Dr McBride:
Yes, it is important that we do that. I will ask Martin and Oswyn to comment briefly on that.
The Chairperson:
I am sorry that I am picking up on Alex Easton’s point, but I know what he was trying to get at.
Dr McBride:
It is important that we answer your question. I think that Martin may have the answer.
Mr Martin Bradley:
Counselling must be framed in a broader context. These are momentous decisions for a woman to face. On one level, counselling is about helping a woman come to terms with the information that she has received, and to come to terms with the diagnosis or clinical assessment. A wide range of issues must be dealt with in a counselling environment.
I know that there is a problem with options. A woman may want to consider — personally — the approach that she wants to take to the pregnancy. That approach will be guided by whether she resides in Northern Ireland and wants to stay here for treatment within the law as it stands here. We live in an open society and community. A range of sources of information is available to women to access in their own right. A woman may want to talk about the available options, but that discussion must happen in the knowledge that some options cannot be exercised in Northern Ireland. A woman may raise the issue of abortion in her own terms, in a healthcare environment. She will have to deal with whatever decision she arrives at, because there will be personal choices to make and freedoms that can still be exercised. However, we must be clear about the services that we can and cannot offer in Northern Ireland. Options will obviously be restricted, but, in a caring environment, we must help women to come to their own decisions about how they exercise their personal freedoms.
The Chairperson:
In other words, if I understand you correctly, you are saying that you would tell a woman that she cannot have an abortion under the guidelines in Northern Ireland, but that she may, if she so decides, go to other parts of the United Kingdom in order to terminate her pregnancy?
Mr Martin Bradley:
No; I do not think that I am saying that. I am saying that, in the context —
The Chairperson:
That is the only way that —
Mr Martin Bradley:
In the context of a clinical assessment, there is a difficult conversation to be had about what that assessment reveals. Does it meet the criteria that apply in Northern Ireland? If it does not, it does not.
Dr McBride:
That is an important point. I apologise; the penny was a bit slow to drop there. The points that both Mr Easton and you make, Chairperson, are covered in the section of the departmental guidance that deals with counselling. I am grateful to Oswyn for drawing that to my attention.
It is stated in paragraph 5.6 of the Department’s consultation paper that advice may be given:
“When termination of pregnancy is considered appropriate within the law in Northern Ireland”.
The important words are:
“within the law in Northern Ireland”.
Martin Bradley mentioned that important context, in which the guidelines state:
“adequate information, support and counselling by appropriately trained staff should be available”.
You made the point that, if it is not appropriate within the law, advice cannot be given.
The Chairperson:
Under those circumstances, advice to terminate cannot be given.
Dr McBride:
That is correct. As Martin said, sources of information from a variety of organisations, including pro-life and pro-choice groups, are available for women.
The Chairperson:
It is illegal for any statutory agency under the NHS to give advice that suggests that a woman go elsewhere if she does not fall into the two categories.
Dr McBride:
I am not a lawyer, so I cannot answer that legal point. As we said earlier, it would not be appropriate for a healthcare professional to refer a patient to a service for termination of a pregnancy if that were unlawful in Northern Ireland. I wish to make that clear.
Mr Paulin:
The guidelines on counselling are quite clear, because they deal with situations in which termination of pregnancy is considered appropriate. As stated in the guidelines, termination must be within the law of Northern Ireland, and counselling would come into play if it were.
Referral to England has been mentioned. The Department’s statutory duty is to provide a Health Service in Northern Ireland, and that must be provided within the law. It would not be lawful to provide termination facilities that are outside the statutory provisions of the Offences Against the Person Act 1861 and the Criminal Justice Act ( Northern Ireland) 1945.
Dr McBride:
The limitation of the guidance is that can refer only to the law in Northern Ireland. The guidelines cannot cover eventualities that would not be lawful in Northern Ireland, because they can state only what is lawful in Northern Ireland.
The Chairperson:
I am trying to pin down whether any other advice on termination of pregnancy is being given. Going to other parts of the United Kingdom for a termination cannot be promoted as an option.
Dr McBride:
The guidance does not promote that; it simply refers to the law in Northern Ireland, and explains the legal position and the responsibilities under which healthcare professionals must work.
Mr Buchanan:
Is it lawful in Northern Ireland to counsel a woman on abortion if her situation does not fit the two or three criteria that are laid down for abortion’s being legal?
Dr McBride:
In the circumstances you describe, termination of pregnancy is not lawful in Northern Ireland. Therefore, that is outwith the remit of the guidance. Under the Court of Appeal ruling, the Department was found to be in breach of its statutory duty to provide guidance to professionals in Northern Ireland on the explanation of the law in Northern Ireland. The guidance refers only, and can refer only, to the law as it currently stands in Northern Ireland. It cannot refer to other situations, which, as you have outlined, are outwith the law on termination of pregnancy in Northern Ireland.
Mr Paulin:
It is common knowledge that the Abortion Act 1967 applies in Great Britain and that people can go there to have a termination. Very few people do not know that, so I do not see how repeating it can be unlawful. To encourage or promote abortions abroad may be different. However, we are discussing what our Health Service can do, not what those outside it can do. The guidelines are directed at Health Service professionals, such as doctors and nurses, not the wider public. In trying to explain how the law applies to the Health Service, we should not stray into what people outside it can or cannot do.
The Chairperson:
Therefore, voluntary groups that do not come under your remit could advise women to travel outside of Northern Ireland to have an abortion, because they are not bound by any of the guidelines.
Mr Paulin:
The guidelines are not directed at such groups.
The Chairperson:
Therefore, those groups can advise women to go to England or elsewhere for abortions and will not be considered to be acting inappropriately?
Mr Paulin:
Yes, and that is happening at present.
Dr Deeny:
Thank you for the presentation. As a member of the Committee and a GP, I regard abortion as a very important issue. We must get the guidelines correct, because they are so important.
It is stated in paragraph 3.3 of the guidance that the mental-health assessments of women aged 18 and over should be carried out by any consultant general adult psychiatrist, a GP or a consultant obstetrician. I have serious concerns about that. I am a senior GP and am very experienced, but I do not want to be in that position, and I do not think that I am qualified to be. Such assessments should be done by an expert in the field, such as a consultant psychiatrist. What are your views on that?
I mentioned the timing of counselling in the previous presentation. It is stated in paragraph 3.1 of the guidance:
“All clinical assessments should be completed in a timely manner and without undue delay”.
That seems very hasty. It is stated in paragraph 5.8 that the purpose of counselling is to allow women to make an informed choice. The choices include:
“medical interventions, adoption services and support available for continuing with the pregnancy.”
There is a complete contradiction between those two paragraphs — on the one hand, there is haste, yet, on the other hand, a great deal of stuff has to be talked about.
I wish to speak about conscientious objection, about which Dr McDermott spoke earlier. I care for all patients at all times, regardless of what they have done — if a patient takes an overdose, I will treat him or her, because that is the duty of a doctor. However, I would object to playing a part in a process that ends in a woman’s having a termination. It is stated in paragraphs 4.1 and 4.2 that doctors have to refer someone who is considering a termination. However, in its letter to Dr McDermott, the General Medical Council states:
“As you will see, the duty to assist patients in obtaining information about a procedure to which the doctor has a conscientious objection applies only where the procedure in question is lawful in the jurisdiction in which the doctor is working. The guidance was drafted in this way primarily to ensure that it accurately reflected the legal position on termination of pregnancy across the UK.”
Therefore, the duty of a doctor to assist patients in obtaining information applies only when the procedure in question is lawful. Abortion is not lawful in Northern Ireland, so that duty does not apply to GPs here.
I make no apologies for being a pro-life doctor — if one of my patients is pregnant, I consider myself to have two patients, and I hope that a counsellor would do the same. Two issues are not mentioned in the guidelines. First, the 1967 Act mentions a 24-week cut-off date, but the guidelines do not mention any such cut-off date. Therefore, if a person from here met the criteria for having an abortion, that raises the concern that that abortion could be carried out at any point until the woman reaches full term.
Secondly, if, for example, a healthcare professional, such as a nurse who works in a hospital, felt that a consultant were acting outside the law, what would his or her responsibility be? If we feel that a fellow healthcare professional is underperforming, putting patients at risk or acting outside the law, we have a duty to report it. There is no guidance on that either.
Dr McBride:
I will say from the outset that you are absolutely correct — a doctor’s first obligation is to treat his or her patient, respect the views and beliefs of that patient even when those differ from the doctor’s personal views, and act in the best interests of the patient at all times.
It is the case that no doctor, at any time, should work beyond their area of competence when it comes to making a clinical assessment. For example, Dr Deeny, you have indicated your concerns about making a mental-health assessment and if, as a general practitioner, you do not feel competent to be involved in that assessment, it is clear that you should not be assessing or providing advice, or support, to patients with mental-health problems. In those circumstances, any doctor or healthcare professional should be seeking input from another healthcare professional who has the relevant expertise and competency in that area.
The guidance is clear about the importance of involving a consultant psychiatrist in the mental-health assessment of persons with a prior mental-health problem — whether that be a severe mental illness or a severe learning disability. Dr Deeny is correct to say that, for those over the age of 18, the guidance indicates that the mental-health assessment can be carried out by a general consultant psychiatrist, a GP or a consultant obstetrician.
What is important is that the guidelines mention that that person must have experience. However, that should be understood as having experience and competency in making such an assessment, and no doctor should be involved in making an assessment if he or she does not feel competent to do so. The guidelines are also quite clear that, according to the law in Northern Ireland, a child and adolescent psychiatrist should be involved in the mental-health assessment of persons under 18 years of age.
During the course of the consultation, we received similar responses on several issues — including the issue of the mental-health assessment — from the Royal College of Psychiatrists, the Royal College of General Practitioners, the Royal College of Obstetricians and Gynaecologists, and the General Medical Council.
No doctor should be involved in assessing any patient if he or she is not competent to do so — that is to do the patient a disservice. Oswyn will now talk about the 1967 Act and the interpretation of the GMC advice.
Mr Paulin:
I shall deal with the GMC advice first. The guidance states that the position is that termination is lawful in Northern Ireland in certain circumstances. Those circumstances are when the mother’s life is at risk or there is a real and serious concern about her ongoing health. Nonetheless, some doctors may have a conscientious objection to providing termination for, or assisting, a woman in the circumstances when an abortion is lawful in Northern Ireland. The guidance states that in those circumstances, the doctor should send the patient to another doctor who does not have those objections.
The 1967 Act applies to England, Wales and Scotland, and provides four bases for the legal termination of pregnancy. One of them is governed by the 24-week cut-off point, before which it must be decided whether the continuation of a pregnancy would involve a greater risk of injury to the physical or mental health of the pregnant woman, or to that of her existing children, than if the pregnancy were terminated. Therefore, the 1967 Act refers to injury, not to a risk of real and serious damage.
I think that that is the broadest ground for termination, but it is not available in Northern Ireland. The 24-week limit applies only to that ground; it does not apply to the mother’s life being at risk, or to a risk of real and serious damage to her health. In England and Scotland, the 24-week limit applies only to certain types of termination that are not available in Northern Ireland.
Dr Margaret Boyle (Department of Health, Social Services and Public Safety):
I shall add a little on that issue and also to pick up on another point. We are talking about termination of pregnancy in order to preserve the life of the mother — or if there is likely to be a serious or long-term effect to her physical or mental health — so there may be occasions beyond 24 weeks in which the mother’s life is in grave danger, and it may be necessary to terminate the pregnancy.
Dr Deeny mentioned, in one case, the need for assessment with undue delay, and, in another case, the woman’s need to have time to consider the options. Again, it is important to look at particular circumstances. There will be occasions when the mother’s life is in imminent danger, and it is therefore imperative that an assessment be made with undue delay. There are other occasions when continuation of the pregnancy will have a permanent or long-term and serious effect on the physical or mental health of the woman, but the danger may not be imminent, so the mother will have some time to consider her options. There are some occasions when a decision must be made in a matter of minutes; there may be others when it can be delayed for days or weeks.
Dr Deeny:
In section 3 of the guidance, which deals with clinical assessment, it states:
“All clinical assessments should be completed in a timely manner”.
That may need to be reworded.
Dr Boyle:
The assessment should be carried out, and the woman may then have time to reflect on its outcome. However, if someone were referred to an obstetrician — or to another clinician, depending on the particular health problem — that assessment should be carried out relatively quickly, so that the woman did not face a long wait, concerned about her health.
Dr McBride:
We will take that point about the wording in the guidance on board, Kieran, as well as all the other points and suggestions for further clarity that have been made.
Dr Deeny:
One question was not answered. It concerns the three types of doctor that can carry out a mental-health assessment. GPs may see many people with depression, but, with no disrespect to consultant obstetricians, I do not know what experience they have of mental-health issues. That is just my view. Certainly, psychiatrists and GPs deal with many cases of people with depression. I may be undermining my fellow doctors, who may have much more ability in diagnosing mental-health problems than we think, but obstetricians, by and large, do not. Moreover, if a member of staff is concerned about a fellow health professional whom they feel may be acting outside the law, no guidelines are available on what that member of staff should do.
Dr McBride:
That is not within the remit of the guidance, which explains the framework within which termination of pregnancy is legal in Northern Ireland. However, there is clearly an obligation on us all to abide by criminal law — whether we are healthcare professionals or members of the public. If we are aware that someone has committed a criminal act, we have an obligation to report that criminal act. Otherwise, unless there is a reasonable excuse, we ourselves are liable to criminal prosecution. Oswyn, is there anything you wish to add?
Dr Deeny:
Before you do, the facts of life are that it will be very difficult for a nurse to report a consultant — let us be honest about that. Perhaps some provision should be written into the guidelines to give them some security.
The Chairperson:
Do you mean a provision in the guidance for cases of whistle-blowing?
Dr Deeny:
Exactly. Health professionals may well be reporting their senior, so they would be worried about losing their job. That is not mentioned in the guidance, and it is assumed that we will all do it as individuals because it is a criminal matter, but people must feel secure in doing that.
Dr McBride:
You make a valid point. Obviously, the guidance cannot cover all eventualities, but the Department issued a circular on whistle-blowing some years ago that clearly indicates, as the Chairperson has mentioned, that, when individuals have concerns, not only should they raise those, but they have a professional obligation to do so.
If they do not raise those concerns, then they themselves may be liable to the professional body for not doing so. There is a professional obligation on doctors, nurses and other healthcare professionals to raise those concerns, and the organisation within which they work has an obligation to protect those individuals where those concerns have been raised in good faith.
Ms Hanna:
I am concerned that the guidelines are non-specific in nature. As this is happening on the back of a judicial review, I should have expected to see the judge’s determination right up front, along with the very limited circumstances in which abortion is available. Lord Justice Nicholson’s determination was a very pro-life one, and that was clear. He stated that the intention was to “reduce the number of women” seeking abortion. That was at the top of his determination.
Other members have brought up various issues about informed consent and independently accredited counselling. I appreciate that, as you have said, there may be an emergency, but I think that it needs to be clearly written in that, except in an absolute emergency, there has got to be independent counselling and a cooling-off period. In other words, the woman has plenty of time to consider the termination.
The very limited circumstances in which abortion is available are not mentioned. I think that it has to be very specific. Dr Deeny has brought up your whistle-blowing policy, and we know about that. However, we are talking about life and death here, so I think that it needs to be very specific. We are talking about very limited circumstances, and that needs to be very clear. Reading the document, I do not think that that is clear. It is more about when abortion is available than when it is not available. If the decision is made to have an abortion in those very limited circumstances, that needs to be very clearly documented. The reasons need to be documented, there needs to be a signed statement of consent, independent counselling has to have been provided. It is not just an option; before anyone can make that decision, that counselling needs to be available.
I also think that parental involvement is essential where minors are involved, and particularly where there are young people with learning disabilities. Legally, there is a grey area around non-judgemental counselling. The counselling has to be independent and offered by accredited counsellors. Abortion is illegal here except in very rare circumstances, yet we have clearly heard today that the three options are to have the baby, have an adoption or have an abortion. A woman would be counselled to have an abortion even though we do not have abortion here. It is only available in very limited circumstances — life or death; whether it affects mental or physical health. I think that there is a grey area there which needs to be teased out further.
Dr McBride:
In the layout of the documentation, we were very clear that we wanted to set out the legal principles within Northern Ireland at the outset. After the introductory section about the purpose of the guidance, we have gone straight in on page 1 to the current law on the termination of pregnancy in Northern Ireland. We have attempted, in the construction of the guidance document, to ensure that it is upfront and central.
The Chairperson:
Professor John Keown has given a statement on the guidance. Your opening paragraph states very boldly:
“Within the scope of this guidance and the law in Northern Ireland, each Health & Social Services Trust must ensure that its patients have access to termination of pregnancy services.”
Professor Keown said:
“This is seriously misleading … The starting point of the Guidance should have been a clear statement of the illegality of abortion in Northern Ireland: that it is a crime punishable by a maximum of life imprisonment to use any means with intent to procure miscarriage, and an offence to supply means knowing that they are to be used with that intent.”
In other words, you have put the cart before the horse; you have not clearly defined the law as it pertains in Northern Ireland. You have done everything but underpin the fact that abortion is criminal and illegal. I should be happy to give you a copy of that statement.
Dr McBride:
I have seen the statement.
The Chairperson:
I am at a loss to understand why that was not clearly stipulated. Before one does anything, one must be aware that termination is illegal, except for —
Mr Paulin:
The law is clearly stated in paragraph 2.2:
“operations .. for the termination of pregnancies are unlawful unless”.
It then explains what “unless” means. There is then a reference to the statutory provisions, and the Chief Medical Officer has indicated that we will amplify those references.
The Chairperson:
My point is that that should be clearly stated at the beginning of the guidance. The fact that the termination of unwanted pregnancies is illegal should be the first point made and boldly highlighted.
Dr McBride:
Your point is well made; however, we should consider the audience of healthcare professionals for which the guidance is intended.
The Chairperson:
Yes, but unless i’s are dotted and t’s are crossed, there will always be an opportunity to —
Dr McBride:
I accept that, but the guidance is written to explain the law in Northern Ireland to doctors, nurses and healthcare professionals working in trusts. As Mr Paulin said, paragraph 2.2 clearly states:
“operations in Northern Ireland for the termination of pregnancies are unlawful”.
I do not believe that we can be any clearer than that. It goes on to state:
“unless performed in good faith for the purpose of preserving the life of the woman”.
It goes on to explain what those circumstances are. Therefore, I take your point, but —
The Chairperson:
I cannot get past the fact that the guidelines that are being submitted for consideration begin with:
“Within the scope of this Guidance and the law in Northern Ireland, each Health & Social Services Trust must ensure that its patients have access to termination of pregnancy services.”
Mrs Hanna:
That was my point; that is the first sentence.
The Chairperson:
That is the first thing that is stipulated.
Dr McBride:
Again, I would add that it says:
“Within the scope of this Guidance and the law in Northern Ireland”.
That qualifies the statement.
The Chairperson:
What is the difficulty with stressing at the beginning that the termination of pregnancy is illegal?
Dr McBride:
The document’s presentation was not intended to hide that fact, and we will take account of your opinion —
The Chairperson:
We feel strongly about that. It should be pinned down.
Dr McBride:
We will certainly take that point away; it is a question about the layout of the guidance. We do not disagree about the intent, and we will reflect that in the final guidance document.
Mrs Hanna:
That was the point that I was making. Given that these guidelines are the result of a judicial review, it is important that the document be upfront about the fact that terminations are illegal, apart from in limited circumstances. I am concerned that the first point made is that everybody must have access to termination.
Dr McBride:
So you would prefer that —
Mrs Hanna:
Yes; it would make more sense to reflect the legal judgement at the beginning, because that is the law as it stands.
The Chairperson:
It is a key point of the law.
Mrs Hanna:
It would make more sense.
Dr McBride:
We recognise that Lord Justice Nicholson’s comments were written in the hope that the Department would seek to reduce the number of women and girls who go away to seek a pregnancy termination and encourage them to consider making a different choice.
Those comments are not part of the order of the Court of Appeal, and the guidance was developed on the basis of the order. However, with that said, the Committee is aware that the guidance goes on to state clearly that women should be made aware of all the alternatives available to them, and that any consent should be fully informed. The Committee is also aware of the efforts that the Department has made to reduce the numbers of teenage pregnancies through its teenage pregnancy and parenthood strategy. It has been successful; and there has been a significant reduction in the rate of teenage pregnancies. We have achieved an 18% reduction in the number of those occurring to girls under 19 years of age, and a 27% reduction of those occurring to girls under 17 years of age, as highlighted in the recent Northern Ireland Audit Office report.
As I said earlier, the new sexual health promotion strategy and action plan which the Committee considered and endorsed in May or June contains specific targets for increasing the age of first sexual activity and reducing the rate of births to teenage mothers. We have been through other approaches and policies to address the issue.
Mrs Hanna:
We all accept that.
Dr McBride:
I know that many members of the Committee share the sentiment of Lord Justice Nicholson’s ruling.
Mr Holland:
There are no special legal requirements relating to consent with regard to abortion. The law in relation to consent and abortion is the same as the law in relation to consent and any other medical treatment. In the case of someone who is deemed to be incompetent through a learning disability, it would, ultimately be for a court to declare whether it would be legal for an abortion to be performed in the best interests of the patient. In the case of a minor, the determination is whether he or she is competent to consent to the particular course of medical treatment. I am sure that members are aware of the Gillick principle of competence.
Mrs Hanna:
Is there an age limit on the necessity to seek parental consent for a surgical procedure or operation — an appendectomy, or whatever — to a minor? Does a parent ever have to give consent for an operation on a minor?
Mr Holland:
No. If the minor is capable of demonstrating a sufficient degree of competence to give consent, parental consent is not required.
Mrs Hanna:
Is that the case for any surgery or procedure?
Dr McBride:
The Department issued guidance on this in 2000.
Mrs Hanna:
I am not sure. That is why I ask.
Dr Boyle:
The minor must have understanding of what he or she is consenting to. If that is demonstrated, consent can be given without reference to the parents.
Mrs Hanna:
It is very subjective. If my child develops a toothache at school, the school will phone me before giving out Panadol. It seems bizarre that someone can judge whether another is competent to make a decision. This is a big decision for a minor.
Dr Boyle:
I agree. Ideally, the parents should be involved: every healthcare professional would want that. They would encourage the minor to involve the parents. However, if a minor has been assessed, is deemed competent to give consent and does not want the parents to know, the health professional cannot inform the parents.
Mrs Hanna:
It might be helpful to have more clarity about that in the document.
Dr McBride:
The document references the 2003 guidance which the Department issued in relation to consent, ‘Reference Guide to Consent for Examination, Treatment or Care’, and it specifically references the paragraphs in relation to adults without capacity and minors.
Clearly, if a healthcare professional feels, despite a request not to share information with a third party, that an individual minor’s health or safety is at risk —
Mrs Hanna:
Sometimes it is a child-protection issue.
Dr McBride :
There is an absolute obligation in those circumstances —
Mrs Hanna:
It should be very clear; much clearer than it currently is in the guidelines.
Mr Holland :
If a health professional believes that child-protection issues are involved, that will override the child’s right to confidentiality. There are also specific legal circumstances in which, by virtue of the pregnancy, the health professional in question is aware of an arrestable offence, and there is an obligation to share that information with the authorities.
Mrs Hanna:
That may well be the case if it is an underage pregnancy.
Mr Holland:
It may be — depending on the age of the child.
Another point is that there can be no legal obligation on women to undergo counselling. That obligation does not currently exist in law, so although the guidance states that counselling should be available and provides details about the nature of the counselling that might be provided, there is no legal basis on which to force anyone to undergo counselling. It is a requirement that someone can give informed consent, but there is no capacity to enforce counselling.
Mrs Hanna:
That is fair enough, but it has to be readily available. It certainly has to be offered and encouraged, so that the woman concerned — even in those circumstances — can make a decision that she will not regret later, or a decision that she is very clear about.
The Chairperson:
This might muddy the waters, but am I right to assume that because a minor has the right to decide that they want to terminate their pregnancy — and because they can decide that they do not want their parents involved — the decision comes from the healthcare professional who is looking after the minor? Are you saying that the professional has more input into whether the parents get to know?
Perhaps I am not wording or framing it correctly, but it seems quite appalling that a minor can decide that they do not want their pregnancy to go ahead and can also decide that they do not want their parents to know. That means that it is down to the professional to decide whether the parents should know about the pregnancy. Surely we have got that all wrong. How can a minor be suitably geared towards making a decision about ending a life?
Mr Holland:
A minor cannot decide to have a termination. That judgement must be made by medical practitioners, on the basis of what it is in their best interests regarding legal consequences.
The Chairperson:
Surely that should be underpinned by the parents of the minor being involved in that decision?
Mr Holland:
I do not want to speak for my medical colleagues, but doctors would seek to engage parents in that decision in the vast majority of instances. However, there are specific legal precedents relating to the giving of consent by minors to medical procedures. That is the legal position.
The Chairperson:
But minors should not engage in sex and should not be pregnant at 13 years of age.
Mr Paulin:
In what has become known as the Gillick case in England, Victoria Gillick challenged the notion that doctors did not have to inform parents that their children were receiving contraception treatment. That is where all those legal principles arose, and that is what the legal position is.
It would obviously be extremely exceptional for it ever to occur — and I do not know whether it ever has occurred in Northern Ireland — but that is what the courts have found the law to be in England. We have every reason to believe that, in those exceptional circumstances, that is what the courts would also find here. The issue is about the competence of the child, and the gravity of the decision to have a termination is obviously a much more grave decision than whether to receive contraception. I am sure that that would be a factor in the decision that is taken by the medical professional.
Dr Boyle:
I concur with that. Health professionals encourage young women or minors who plan to have abortions to talk to their parents. That is the ideal situation. If a girl has been assessed as Gillick competent — that they have sufficient judgement and understanding — we must respect her decision not to tell her parents that she plans to have an abortion. Health professionals want and encourage girls to discuss their decision with their parents. However, legally, health professionals cannot tell a girl’s parents that she plans to have an abortion if she does not want them to.
The Chairperson:
If a child, who is obviously under the age of consent, is involved in a sexual act, what legal right does she have to say that her parents should not be told?
Mr Paulin:
On the basis of this case and this decision, girls are not required to tell their parents.
The Chairperson:
It is unbelievable that a minor can decide whether her parents are told that she is going to end the life of a child. I know that the professional makes the decision on whether to terminate the pregnancy, but we are giving away so much. We are not protecting the young person.
Mr Paulin:
We are stating what we believe the law to be.It is not the Department’s policy; it is what the courts have found the law to be.
The Chairperson:
That is going to affect young children in the future. I really do despair. Those woolly liberal thinkers destroy our moral standing.
Mr Buchanan:
Many of the issues and concerns have been discussed. I am alarmed by this discussion regarding minors. I am alarmed that a youngster can terminate a pregnancy without her parents knowing. It is completely outrageous and is something that we must tackle.
Paragraph 7.1 of the guidance document deals with the provision of information to women, with which I have no difficulty. It details what support and information should be given to any woman seeking a termination:
“who does not meet the criteria in full”.
However, I do have a difficulty with paragraph 7.2, which states that:
“Verbal advice should be supported by accurate, impartial printed information that the woman considering termination can understand and may take away to consider before the procedure.”
That really undermines paragraph 7.1. Paragraph 7.2 should be reworded to state that any woman considering termination “and who meets the criteria” should be given information that she can understand and may take away to consider further before the procedure.The wording of that must be changed.
The Chairperson:
Absolutely.
Dr McBride:
Your point is a valid one. Basically, there is an assumption in the writing of the document that paragraph 7.2 follows from paragraph 7.1. Obviously, the whole document applies only to those circumstances in which termination of pregnancy is lawful in Northern Ireland.
The Chairperson:
That is not clear.
Mr Buchanan:
That is not what is stated. Paragraph 7.1 lists the information that should be given to women who do not meet the full criteria, with which I have no difficulty. However, paragraph 7.2 states that women considering termination should be given information that they can understand and consider further before the procedure.
Dr McBride:
Your point is valid.
The Chairperson:
It is very valid.
Dr McBride:
In circumstances where the termination of a pregnancy is lawful in Northern Ireland, advice should be given to the woman. That is a valid point, Tom. We will work on that.
Mr Buchanan:
The wording must be changed slightly.
The Chairperson:
You have heard the Committee’s great disquiet around some issues. I hope that, before too long, those issues will be put right. At the end of the day, we want to be seen to be upholding the laws of Northern Ireland. There should be no ambiguities or grey areas and everybody should be clear. That is only fair, both to the mother and the baby and to the professionals who have to adhere to the legal requirements in Northern Ireland.
I thank you for your time and for answering the questions in layman’s terms.