Motherhood, birth, healthcare, abortion: Ireland can set a new standard of care
The debate and controversy about the care of mother and child through pregnancy and birth, and about abortion, is sometimes made confusing by the way language is used. Emotions can run high. I will try to work around these factors.
It may seem that I have no standing to speak on the question. As a man, I cannot have the personal experience of pregnancy. Although I may be addressed as “Father”, I have not fathered a child. (I hope that I, like any other human being, can be “life-giving” in other ways.) I have no medical or legal qualification. I am not a politician or legislator. Nor am I a professional moral theologian. Despite all these limitations, I would like to reflect on this question, which is very much alive in the wake of the tragedy of the death of Savita Halappanavar and her child in Galway in October, the loss experienced by her husband Praveen, and the widespread reporting on this in Ireland and around the world.
I do not refer here to positions held on a religious basis; rather, I want to approach the matter from the standpoint of human nature, and of care and respect for each human being.
The Beginnings of Human Life
In the case of human pregnancy, it is commonly a cause for rejoicing and anxiety. We speak of “expecting a baby”. An older expression is “being with child”. From conception, the child (called a foetus or fetus before birth) goes through many stages of development, with medical terms for these stages: zygote, blastocyst, embryo. A heartbeat can be detected about 18 to 21 days after conception. A normal range for human pregnancy is from 37 to 42 weeks. At about 17 weeks, the child of Savita and Praveen Halappanavar would normally be about five inches (about 127mm). When the baby was delivered after its death, Savita Halappanavar could know that their child was a girl that they very much wanted, and lost.
A ruling of October 2011 from the European Court says at No. 53:
Article 6(2)(c) of Directive 98/44/EC of the European Parliament and of the Council of 6 July 1998 on the legal protection of biotechnological inventions must be interpreted as meaning that any human ovum after fertilisation, any non-fertilised human ovum into which the cell nucleus from a mature human cell has been transplanted, and any non-fertilised human ovum whose division and further development have been stimulated by parthenogenesis constitute a ‘human embryo’. (Read the ruling here.)
In pregnancy, we want to safeguard the life of mother and child. “Abortion” (in Irish: ginmhilleadh: birth destruction) is usually used for a procedure where part or all of the objective is the ending of the life of an unborn child; failure is a child delivered alive. “Termination of pregnancy” is sometimes used to indicate the same thing, but it has a much wider meaning. Termination is the ending of pregnancy. In most cases this occurs when the child is ready to be born. This may be by natural birth, or assisted in some way by medication or instruments, or by surgery as in Caesarean section. Where there is cause, termination may be brought about before the due time. There is ambiguity in the use of the “termination”, since it is often used as a synonym or a euphemism for abortion. In the Report of the Expert Group on the Judgment in the A, B, and C v Ireland (frequently called the Expert Group on Abortion), “abortion” occurs 156 times and “termination” 88 times, and they are used interchangeably. This Report was published on 27 November 2012. “Miscarriage” occurs when the child is delivered at a stage when unable to survive; this may occur spontaneously or, for example, through an accident.
To “deliver a child” expresses much more clearly what we are about without ambiguity, and can be used also early in pregnancy whether the child’s life is viable at that stage or not.
In normal circumstances, pregnancies result in the birth of a living child. Coming up to the birth is naturally a time of anxiety for mothers and fathers, followed, we normally hope, by happiness and relief. While birth is a natural, although stressful, process, we are blessed in this country with healthcare to assist where problems arise. A lot requires to be done in many parts of the world to move towards the targets 4A and 5A of the UN Millennium Development Goals: To reduce , between 1990 and 2015, by two-thirds, the under-five mortality rate and to reduce by three quarters the maternal mortality ratio.
Problems in Pregnancy
Where a problem arises in the pregnancy, we are faced with the question of how to provide best care for mother and child. This is a developing situation. Some conditions which would have been fatal for the mother 50 years ago can now be managed successfully; so also for the child. Frieda, a child born in November 2010 in Fulda, Germany, at about 21 weeks into the pregnancy survived and came home; her twin brother Kilian died six weeks after birth due to heart and intestinal problems.
For a mother, medical personnel use the best of their skill and care to know when her health and life may be endangered. Article 40.3.3° of the Irish Constitution reads: The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right. Medicine is not an exact science which can always predict outcomes, and medical personnel have to make difficult decisions, sometimes under pressure of fast-developing situations and with less-than-ideal resources.
Sometimes it will be possible to deliver the child before its time and to save the mother. Sometimes, in order to care for and save the life and health of the mother, it may be necessary to act to terminate the pregnancy and deliver the child, even when it is very likely or certain that the child cannot survive, despite the very best care available. This is a sad but real situation. The decision here seems best made between the mother (and father, where possible) and the medical professionals. Some mothers will decide to go ahead with the procedure. Where there may be a borderline decision, some may opt to wait longer to give the child the very best chance. These are most difficult decisions, and every possible support must be available.
I deliberately use the words “deliver the child”, not “abortion”. The purpose here is clearly to do everything possible to save both, whereas abortion involves the purposeful ending of the life of the child. This is what distinguishes the above situation from abortion. Think, perhaps, of an ill person who requires life-saving treatment, which will most likely result in the person losing all hair. This, of course, is relatively much more trivial (although the ill person may not feel it trivial), but the principle is the same. We do not intend the side-effects (like those listed on the leaflet which comes with the medication you have at home), but we accept them regretfully where the treatment is necessary.
The Question Facing Us
Some call for decriminalization of abortion. Professor Sabaratnam Arulkumaran reported that in the UK, “one in five pregnancies ends in termination of pregnancy”. (Obstetrics, Gynaecology and Reproductive Medicine, Volume 17, Issue 10, pages 301-304, October 2007). A report in the Daily Mail (UK) on 4 February 2008 said that
“a total of 66 infants survived NHS termination attempts in one year alone. Rather than dying at birth as was intended, they were able to breathe unaided. About half were alive for an hour, while one survived ten hours … The statistics are contained in the small print of an official report by the Confidential Enquiry into Maternal and Child Health, commissioned by the Government … Guidance from the Royal College of Obstetricians and Gynaecologists recommends babies over 22 weeks which survive abortion should have their hearts stopped by lethal injection but this can be a difficult procedure for doctors.”
This does not seem like a good “solution”, even if abortion procedures were more “efficient” so as to ensure no child would survive the procedure.
There will always be difficult situations. It is difficult for legislators to find a way to frame law in order to provide the best of care and protection for each human being, and to ensure, as far as civil law can, to prevent individuals from exploiting or breaking the law and failing to respect the life of each human being in all its stages. Medical professionals need law to be as clear as possible to facilitate best care without fear of being prosecuted. Those labelled “pro-life” tend to be seen as fearing that the life of the unborn child is devalued. Those labelled “pro-choice” tend to be seen as fearing that the life of the mother is devalued. The challenge is to find a way to safeguard both. I would very much like to see Ireland finding a way which would set a new standard of care for the world in this matter.
Some Principles to Discuss
One thing I remember of my father and mother is their great sense of respect and fairness towards every human being. With that in mind, and to embrace as fully as possible all that the Constitution mandates, I would like to offer for discussion some “principles” which may help to point a way forward. Insofar as the language in the principles lacks the required legal and medical precision, suitable editing would be required.
1. Where a pregnant woman is judged medically to require treatment to save her life, but where the treatment is considered to endanger the life of the unborn child:
a. The required treatment is to be made available to the mother, and applied only with her consent.
b. This treatment is not to be delayed in a way which would endanger the health of the mother.
c. Such treatment is to be administered in such a way that will, if at all possible, safeguard the life of the unborn child.
d. Where, because of the circumstances of the pregnancy, it is unlikely or impossible that the life of the child can be saved, the treatment is still to be made available to the mother.
e. If the treatment administered involves as a concomitant the termination of the pregnancy, the procedure chosen for termination of the pregnancy is to be that which will offer the best possibility for saving the life of the child.
f. In cases of such termination of pregnancy, when the child is delivered and is living, all possible efforts are to be made to save the life of the child.
g. Where it proves impossible to save the life of the child, the body of the child is to be treated with the same respect and accorded the same rights as would be accorded a child in stillbirth or neo-natal death.
h. The child may be registered and named as in the case of stillbirth or neonatal death.
i. Any organ donation in such a case is to follow the normal procedures for organ donation; commercial exploitation is to be excluded.
j. In life and death matters such as these, the Medical Council may consider whether it is most appropriate that the judgment that the treatment required may suitably be made by agreement of more than one suitably qualified medical professional.
k. The place of the father of the child in the decisions should be taken into account.
2. In a pregnancy, where there is a diagnosis that the unborn child has a condition which is considered likely to lead to the death of the child before, during or around the time of the birth of the child:
a. All necessary support is to be provided to the parent(s), as would be the case if the child were already born and living with a condition which endangers its life, taking into consideration that medicine is not an exact science, that misdiagnosis can occur, and that even when the diagnosis is accurate, the estimation of the duration of survival of the child may not be certain.
b. Where the life of the mother is considered endangered by the circumstances, the principles at No. 1 above would apply.
Civil law can never eliminate all difficulties or wrongdoing. The best safeguard is in the value and respect each of us has for each human life at all its stages. Law is necessary for a functioning society, but it is also necessary for mature human living that we internalise the fundamental values involved and not trust just to written laws.
A variety of difficult situations give rise to further debate. Suicide is a challenge far wider than just in pregnancy, and Irish society needs to face that challenge of finding ways of supporting any person who is experiencing “suicidal ideation”. This is the immediate and urgent step to be tackled; abortion seems to me the ultimate, the “nuclear”, option. If I have an infection in my foot which threatens gangrene, I would prefer medical or surgical treatment before we consider amputation.
Similar support is also vital for the cases of an unborn child who is diagnosed as having a condition “incompatible with life”, and for cases of pregnancy following rape and incest. For any parents who feel unable to cope with these situations, we have a duty to ask first what it is that might provide support for the remainder of the pregnancy, so that they do not necessarily feel driven to a termination of pregnancy. We have a strong tradition in families of caring at home, for example, for people of any age with serious illness or handicap. We face difficult economic times, but it is tragic that our government thinks it necessary to cut back on carer’s allowance and home help in these situations. Perhaps local communities and parishes could organise support systems.
The Death of Savita Halappanavar in the Media
At time of writing, we await the results of enquiries into the circumstances surrounding the death of Savita Halappanavar and her child in Galway in October 2012. The media have given the story much publicity. There has been overflowing expression of sympathy and support, which is understandable. It has helped that we have the case of a beautiful young woman, from an exotic country, expecting a first child, and her grieving husband Praveen, and some seemingly insensitive response from statutory bodies. The fact that government and Catholic church are seen as identifiable targets is probably also a factor. It would be sad if there is any exploitation of Praveen in his grief.
It seems to me that many in the Irish media have not served us well. Overwhelmingly, the dominant tone in the print and electronic media and in demonstrations has been that of protest, reinforced even by a group of MEPs and by international demonstrations. The only reason for protesting is where it is believed an injustice has been perpetrated.
Yet we still need an enquiry to ascertain the facts of the case: to know whether Savita was wrongly denied appropriate care, or whether she did receive the care, which was unable to save her. The matter is still sub judice, awaiting judgment, if not in the strict legal sense.
The Minister for Health has advised the public to exercise caution in judging what has happened, but this has had little effect. It is almost as if there has been a spontaneous trial by media and public opinion. Articles by highly respected journalists and commentators have presumed, before we have the full evidence, that Savita and her husband have been wronged. So far we have only heard the story from Savita’s husband. We have yet to hear the story of those who cared for Savita in the hospital. This puts them in a most difficult and stressful position, added to the stress of their work. It may be the case that there was a serious failure of care at the hospital. We do not yet know.
But if an independent enquiry reaches a conclusion that there was not a failure, and that it was an unavoidable tragedy leading to the death of Savita and her child, it is difficult to see how this would receive a fair hearing and acceptance. It would be publicised around the world as a whitewash. It is hard to imagine the media personnel who have pre-judged the case issuing a retraction and apology at the same level as the reporting.
There is also the possibility of serious consequences. The India Times has used the headline: Ireland murders pregnant Indian dentist. In Karnataka, the home state of the Halappavar family, there is a history of strife between the Hindu community and the Christian community in recent years. We cannot control the world press, but they have taken their lead from the Irish media.
Whatever the results of enquiries into the facts, premature rush to judgment is not only unwise, but also dangerous. Our healthcare system deals with matters of life and death. Responsible press and electronic media are also, literally, vital.