Guidance on responding to the public consultation on abortion in NI

The public consultation on abortion in Northern Ireland opened on 4th November. It’s a long read, and the 15 questions being asked demand some thought. To that effect, I’ve summarised it and given suggested responses, based on a Christian and Pro-life perspective.

Foreword

The Secretary of State in his foreword acknowledges that these matters should be decided by locally elected politicians. He expresses sympathy to the sensitivities of the matter. He talks about the balancing of rights and obligations, and a lack of compulsion to providing these services, although in accordance with existing frameworks, presumably relating to GMC and NMC conscience clauses.

Even if an Executive is formed, there is still a legal duty on the Government to bring about changes, presumably in accordance with UN CEDAW legislation.

The purpose of the legislation is to provide a framework for lawful abortion by 31st March 2020.

The key piece of legislation is Section 9 of the NI EF Act, getting rid of the previous protective anti-abortion legislation, and putting a duty on NI to provide an abortion framework by March. This is informed by UN CEDAW legislation.

The document states that the health and safety of women and girls, along with clarity and certainty for the medical profession are its main concerns.

The purpose is to inform the public on new legislation, and to allow us to comment on policy proposals.

They are particularly looking for responses addressing the specific issues which they raise. They aren’t looking for comments on whether abortion is ethically right, or GB legislation, or whether this should be decided locally,

Closing date 23:45 on 16th December 2019!

Who do they want to hear from? “Anyone with an interest or a view on the proposed shape of this legislation”. Especially those directly impacted – organisations representing those affected, healthcare professionals.

Online consultation, email or postal responses, either as individuals or as an organisation.

Any personal information provided is discoverable! You can ask for confidentiality, but it’s not guaranteed. Names will not be published without permission.

Adoption of legislation for abortion in 3 cases

i. Threat to the pregnant woman’s physical or mental health, without conditionality of “long term or permanent effects”.

ii. Rape and incest

iii. Severe foetal impairment, including fatal foetal abnormality, without perpetuating stereotypes towards persons with disabilities and ensuring appropriate and ongoing support , social and financial, for women who decide to carry such pregnancies to term.

Due to the difficulties of defining rape and incest, in order to address UN CEDAW recommendations, they are instead “seeking views on a period of unrestricted access for early terminations, so that termination of pregnancy is available without conditionality, where a pregnancy has not exceeded 12 or 14 weeks gestation”. Their reasoning is arbitrary – 12 weeks is considered the end of the first trimester, and in GB 90% of abortions are carried out before this date. The alternative is 14 weeks, because of a delay in recognising pregnancy.

Question 1 – Should the gestational limit for early terminations of pregnancy be:

Suggestions for response – these are both yes/no answers. I would advise answering ‘No’ on both accounts. Agreeing with abortion at either 12 or 14 weeks, especially unconditionally, goes against our beliefs of life beginning at conception, and the inherent value of human life. There is a box below to discuss alternatives – even though the scope of the consultation does not cover the ethics of abortion, I think it is entirely reasonable to restate our opposition to unconditional first trimester abortion, whether up to 12 or 14 weeks, and to include a brief summation of our arguments on this point.

The next question deals with whether there should be any official medical reporting of abortions. The first option is to have no reporting. This is, of course, madness – in no other field of healthcare do we decline to collect such data. The second option is to have a ‘limited form of certification”

Question 2 – Should a limited form of certification by a healthcare professional be required for early terminations of pregnancy?

Suggestions for response – to answer ‘Yes’ is to agree with a limited and sloppy form of reporting. We can see what has happened in GB – although 2 doctors are meant to sign off on abortions, the opinion of a second doctor is rarely sought, and in fact signatures have been photocopied – this has been brought before professional bodies in the past without disciplinary action. The NI legislation is not even looking for that level of oversight. My response would be ‘No’, followed by the following comments – restating my previous dissatisfaction with unconditional abortion in first trimester, there must be some documentation of reasons for requesting abortion (to allow for proper analysis), along with a fully documented assessment of the capacity of the woman requesting the abortion, looking at issues like her mental state, physical state, lack of evidence of coercion; any surgical procedure must have fully informed consent – ‘Montgomery compliant’, to use the legal term – and for procedures which are riskier or have greater potential to affect a patient in the longer term, then the current thinking is that a ‘cooling off period’ is important, so that the patient has time to think about the information that they have been given, to process it, and to allow them to reach a fully informed opinion on whether or not to proceed – I think the issue of informed consent is an important point to hammer home. There may be other areas which could be stated here.

The first comment made is that later abortion can be sought for social reasons – “relationship breakdown”, and that they may be more vulnerable for “challenging life circumstances”.

The legislation aims to expand abortion in these later cases for watered down reasons – “In cases of a threat to the pregnant woman or girl’s physical or mental health, without conditionality of “long term or permanent effects””. This is no longer a life and death matter – these vague terms give a vast scope for providing abortion for minor mood disorders and minor physical disorders. They give scope to providing abortion for social reasons masquerading as medical problems; basically, if you have the right form of words, and tell the doctor the right story, there would be no grounds to refuse. The only way in which this legislation could be clarified is through courts of law, in all likelihood retrospectively.

The first suggestion is that any 12-14 week limit be scrapped, and viability be adopted as the cut-off (i.e. 24 weeks or thereabouts), leaving these decisions to the physician’s discretion. As we have seen in many cases in GB, doctors are human beings with a wide variety of opinions, and with legislation as potentially nebulous as stated above, then there will be those who will deviate to the liberal side of the spectrum, and will sign off abortions for practically no justification – I envisage a ‘shopping around’ process, whereby pregnant women will be go to the lowest common denominator – likely an independent abortion provider. Any capacity to reason with someone requesting abortion, or to offer support and provision will be reduced.

On a slightly positive note, mention is made of lowering age of viability to 22 weeks, and also looking at international legislation.

Question 3 – Should the gestational time limit in circumstances where the continuance of the pregnancy would cause risk of injury to the physical or mental health of the woman or girl, or any existing children or her family, greater than the risk of terminating the pregnancy, be:

Suggested response – I would suggest ticking ‘No’ for both of these options, then commenting below – I think there is scope here to highlight the increased survival of pre-term babies, to draw attention to so-called ‘heartbeat bills’ in the USA, and also to look at research about foetal pain in first trimester. I would be arguing that the existing legislation, whereby abortion is only an option for life and death scenarios, is fit for purpose.

The first paragraph highlights the sensitivity of this issue, and also deserves credit for consideration of time for the family to “understand the nature and severity of the condition, so they are able to reach an informed decision about how to proceed”. There are plenty of stories from mothers of children who have been in this position, and have been pressured throughout their pregnancy into abortions, or repeatedly offered abortions, for example in the case of Downs syndrome.

The GB legislation is mentioned, whereby abortion up to birth is allowed for pregnancies where two doctors agree that “there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities to be seriously handicapped”. Abortions for this reason in GB were 1.6 % of the total, a relative drop in the ocean, but not something that we can wash over or neglect.

The document proposes that there should be legislation for abortion in cases of serious or foetal abnormality – the question from them is, how severe must the abnormality be?

Question 4 – Should abortion without time limit be available for foetal abnormality where there is a substantial risk that:

Suggested response – My recommendation is ‘No’ to both questions. There are many reasons, of which I shall mention a few. Firstly, the inherent dignity and value of someone with disabilities should not be subject to killing by another under some misplaced sense of ‘compassion’. Secondly, prenatal diagnosis is not an exact science, as witnessed by the recent tragic case in the Republic where a child was misdiagnosed with Edwards syndrome in the womb, then aborted, but subsequently found, on post-mortem, to be genetically normal. Thirdly, I feel it is more compassionate to allow a woman to carry a child, even if they were to be delivered stillborn, or to die shortly after birth, to allow proper grieving, in the context of perinatal hospice facilities and compassionate maternity care, rather than to surgically kill a living child, no matter how poorly they might be. Fourthly, estimating the degree of future impairment of a child while they are still in the womb is a shot in the dark, and can bear little reflection to the child’s outcomes. Fifthly, the result of increased abortion for non-fatal abnormalities will remove a precious and respected subsection of people from our community, people who bring warmth and delight to a great many, even if they don’t have a functional purpose and use increased resources. Sixthly, it demeans people with disabilities if their unborn counterparts are aborted, and devalued. Seventh – we have no idea of the future of a child’s life – taking Downs syndrome as an example – life expectancy has improved greatly over the last few decades, and who knows what may be possible in future years with some conditions currently considered to be life limiting? There are many more arguments that could be used here.

The current legislation allows for abortion in these very limited circumstances – if the mother’s life is in danger, but also if there is a risk of severe permanent harm. Practically, it is difficult to separate these two categories. The original draft guidelines for the interim period stated that 12 abortions were carried out in NI for these reasons in the previous year, all of which had to be justified thoroughly, or else done in an emergency setting. The proposal is to bring the NI legislation into line with GB, which has similar provision, and similarly small numbers of cases.

Question 5 – Do you agree that provision should be made for abortion without gestational time limit where:

Suggested response – I think that is reasonable to select ‘Yes’ for both, with the proviso that the second question may be difficult to pin down, and I can’t think of any cases where this has been recently used, to my knowledge.

In England and Wales most abortion services are provided by independent sector organisations who contract their services to the NHS; in Scotland they are mostly performed in NHS hospitals. In GB abortions may only be carried out by a registered medical practitioner, i.e. a doctor. The proposal is that this would be extended to “any other registered healthcare professional” who was “appropriately trained and competent”, opening the doors to nurse or midwives being trained to do this role.

Question 6 – Do you agree that a medical practitioner or any registered healthcare professional should be able to provide terminations provided they are appropriately trained and competent to provide the treatment in accordance with their professional body’s requirements and guidelines?

Suggested response – I would answer ‘No’. I don’t believe that it should be the responsibility of anyone within the medical, nursing or midwifery professions to provide terminations. It is not a matter of competency and training for what is usually a straightforward and relatively simple procedure – these duties fall outside a historical understanding of the roles of doctors, nurses and midwives, and outside of the these roles as recognised by a substantial proprortion of these professions in Northern Ireland.

The push in this document is to move away from abortions happening on NHS premises, in gynaecology wards or day procedure units, towards a ‘flexible’ service, looking at home administration of medical abortion medication, for example.

Question 7 – Do you agree that the model of service delivery for Northern Ireland should provide for flexibility on where abortion procedures can take place and be able to be developed within Northern Ireland?

Suggested response – if the underlying thrust of this question is, should we be able to make access to early abortion for any reason easily available in the comfort of one’s own home, then I think we need to answer ‘No’. On one hand, we don’t want abortion in NI, inside or out of a hospital. On the other hand, if it is to be foisted upon us, then we don’t want to be involved directly as individuals, and don’t want our colleagues in other roles to be impacted by it.

The next paragraph looks at abortions beyond 24 weeks, and whether or not they should take place in NHS hospitals, due to the limited grounds for abortions in these settings, higher risk of complications, and longer stays.

Question 8 – Do you agree that terminations after 22/24 weeks should only be undertaken by health and social care providers within acute sector hospitals?

Suggested response – in the context of this happening in a limited number of cases, where maternal life is at risk, then the reasonable response is ‘Yes’. If abortion is to be allowed for spurious reasons up to birth, then the response is a more guarded ‘Yes’ – allowing independent sector organisations with a bias to providing abortion services free rein in this area would be problematic.

For proper governance, any healthcare professional should follow best practice based on evidence and be able to audit their processes and outcomes. This would also, rightly, apply to anyone performing an abortion. The document looks at GB practice, whereby two doctors must sign off that an abortion meets the legal and medical criteria. They rightly look at our Northern Ireland context and consider that this may be difficult, given the level of objection amongst healthcare staff – basically, finding a second doctor to sign off on an abortion may be difficult.

The proposal, then, is that only one “medical or healthcare professional who forms an opinion in good faith, based on their expert medical opinion, that a termination after 12/14 weeks meets relevant criteria is sufficient”. Please note, dear reader, that first trimester abortions are likely not to be subject to this. Also, the term ‘expert medical opinion’ is a strong one – I would be reluctant, as a doctor, to write this on any document, or give a statement like that on any medical question, certain or otherwise.

Question 9 – Do you think that a process of certification by two healthcare professionals should be put in place for abortions after 12/14 weeks gestation in Northern Ireland?

Suggested response – ‘No’. Asking us to agree that abortion is warranted in these settings is not legitimate. On the second point, the response should be ‘No’ again – anything which lowers the barrier to the access to abortion cannot be helpful. The lack of availability of suitably trained staff to oversee a medical procedure should not result in the lowering of clinical standards – this is a patient safety issue, and I think this should be highlighted strongly. It doesn’t matter that, in practice in GB, the second doctor is seldom consulted, that’s not the point.

The document quite rightly highlights the importance of proper reporting procedures for abortions in GB, in order that there should be appropriate scrutiny.

Question 10 – Do you consider a notification process should be put in place in Northern Ireland to provide scrutiny of the services provided, as well as ensuring data is available to provide transparency around access to services?

Suggested response – ‘Yes’. We absolutely want to see good data – this is not something that can be pushed under the carpet – the example of physician assisted suicide in Canada not being subject to statutory reporting would be the alternative scenario – in that case, there is absolutely no oversight, scrutiny, governance or critique of what is happening, which is again contrary to all perceived wisdom in clinical medicine.

The proposal is that there should be a statutory right for healthcare professionals to “object to the provision of treatment relating to a termination of pregnancy to provide a clear legal position”. This is similar to legal provision in the rest of the UK. The document states that this legislation would not include “ancillary, administrative and managerial tasks that might be associated with that treatment”. This, of course, does not allow for secretarial staff, cleaning staff, CSSD staff and many others to object to being involved in, for example, organising appointments for abortions, organising rotas for abortionists, or cleaning theatres and equipment used in abortion, something which has the potential to cause a great deal of distress to colleagues in the health service.

Question 11 – Do you agree that the proposed conscientious objection provision should reflect practice in the rest of the United Kingdom, covering participation in the whole course of treatment for the abortion, but not associated ancilliary, administrative and managerial tasks?

Suggested response – I would recommend ’No’. I believe that the conscientious objection provision in GB is insufficiently wide ranging to protect the full spectrum of healthcare and ancilliary staff who have ethical issues with being involved with abortion. It is not enough to restrict this provision to those directly involved with the procedure, while ignoring the concerns of those who strongly disagree with the whole concept of abortion. Northern Ireland should be considered as a separate and different case from the rest of the UK because of the historical and cultural objections to abortion, and the fact that this is not the will of the electorate. Our staff have not chosen to be involved in these procedures, have not had to be involved with these procedures, and many people are absolutely opposed to these procedures.

Question 12 – Do you think any further protections or clarification regarding conscientious objection is required in the regulation?

Suggested response – ‘Yes’. I would restate what I have said above, that provision for conscientious objection be made for all staff, whether involved directly with the procedure, or not. Secondly, professional guidance dictates that medical staff who object on the grounds of conscience to a procedure are compelled to refer the patient to another practitioner without those objections – the very act of doing this is to be a party to an act which goes against many doctors, nurses and midwives’ deeply held beliefs, and would be an assault on their consciences. The recommendation would be that healthcare staff should not be compelled to refer these patients on. Reference could be made to the recent World Medical Association recommendations on euthanasia, that doctors who object should not have to refer patients requesting euthanasia on to another practitioner.

The document recognises the right to peaceful protest, but then goes on to highlight the UN CEDAW recommendations , that they “protect women from harassment by anti-abortion protesters by investigating complaints and prosecuting and punishing perpetrators”. It goes on to describe the infrequent use of Police powers in GB in these settings, and comments that there are no equivalent powers in Northern Ireland.

The document makes the comment that the expected provision of abortion services will be in a Trust-based clinic or hospital, and that any protest may be detrimental to other patients. There seems to be an expectation that new powers may be needed to handle this, bringing in exclusion zones.

They quite rightly point out that there is a balance of rights and freedoms to be considered.

Question 13 – Do you agree that there should be provision for powers which allow for an exclusion or safe zone to be put in place?

Suggested response – ‘No’. I would make the point that this is a very different issue to that of abortion, and should be considered separately. Precious little time was devoted in Parliament to the debate on this legislation, and it would do a great disservice to the people of Northern Ireland to have our freedoms potentially restricted in these ways. I would strongly recommend that any such considerations would be left to a devolved Executive in Northern Ireland to decide. In the absence of any real-life incidences, there is no need to pro-actively put in place powers which would potentially impinge on the rights of citizens of Northern Ireland to freely assemble, protest, speak their minds in the public square without fear of censure, meet together in public without Government permission for the purposes of a service of worship, read the Scriptures and pray in public; many other potential implications could be considered here.

Question 14 – Do you consider there should be a power to designate a separate zone where protest can take place under certain conditions?

Suggested response – ‘No’. Restrictions on the exercise of the rights mentioned above, and in the document should not be brought into place as part of this abortion legislation. This is an issue which should be considered separately, by a devolved Executive in Northern Ireland. It is inappropriate to introduce this on a ‘just in case’ basis, and there would be deep seated concerns over the use and abuse of this legislation to restrict protest on a wider basis.

Question 15 – Have you any other comments you wish to make about the proposed new legal framework for abortion services in Northern Ireland?

Suggested response – At this stage, it would be appropriate to make a short statement to register our opposition to the introduction of this legislation, listing your job title and role, if appropriate. It may also be appropriate to make a short comment on our desire that appropriate and compassionate care should be provided to mothers and their unborn babies – the best form of care being excellent antenatal provision, excellent maternal care and excellent provision for mothers in the wider society – this is the gold standard of healthcare for women and girls who are pregnant, no matter what their situation. It may be appropriate to put a short summary of your beliefs on the value of human life and the duties of the Government to protect the most vulnerable in society.