I’m not
going to recap the talk from last night. So my apologies to those not in
attendance, particularly where my references don’t make sense. It was
fantastic, and I needed to write this.
When I RSVP’d to attend this
month’s Leadership Lecture Series, I was middle of the road about it. I get CPD
points. It’s free because of my employer. And having attended a good number
over the past two years, they tended to blow a bit hot and cold; fascinating
people sometimes gave rather dull talks, or lesser-known people really sparking
up a good chat. I knew Dearbhail McDonald was going to be giving the
talk—“Lessons in Leadership”—and the blurb was, well, bland. But, in spite of
the weather, I left work and made my way down to the college, sat in a packed
out Albert Lecture Theater with only a few familiar faces and one actual
friend, and wondered which way the evening was going to go. I am so glad I
went.
Forgoing the traditional powerpoint
lecture slides, Dearbhail gave a room of men and women, clinician and administrators,
people across the political and age spectrums a concise and personal,
contextualized history of the 8th Amendment to the Irish
Constitution. It was impassioned and thought-provoking without being
politically ostracizing. It was accurate without being filled with jargon, and
as a clinician, I didn’t feel it was dumbed down either. It was a call to arms.
It was brave. It was powerful. It was the longest post-talk Q&A of the
Lecture Series (that I’ve attended). And I feel, after having slept on it, it
deserves a response.
I in no way disagree with anything
Dearbhail said. Aside from the accurate and understandable breakdown of the
fumbling legal course of the 8th Ammendment and 40.3.3, she was not
there to convince anyone that their opinions on abortion are right or wrong. I
want to respond to the thoughts that bounced around my head during and after
her talk, that stemmed from the Q&A, that burrowed into my brain overnight.
So Dearbhail, thank you for kicking this conversation into motion. It needs to
be had.
First, let me just qualify my
position, my allegiances, my biases, my privilege. I’m an American ex-pat; the
product of Irish-American parents, displaced from Yankeedom to the Midwest,
both of whom were horrendously supportive of my brothers and myself; and I’ve
lived in Ireland long enough that Dublin has been “home” for nearly a decade.
My education is a hodge-podge of Montessori, public (that’s the American
version of ‘public,’ not the British) & private, Episcopalian &
Anglican, and Catholic, and taken from three different countries.
At the age of eighteen, one of my
friends had an abortion. She did it on her own and it was kept secret. At the
age of twenty, studying abroad for a semester, I was assaulted and it was kept
a secret. And we all left home for college. At the age of twenty-two, teaching
in South Texas, I was asked if I was married. When I answered, “No,” the
response was, “Oh, no. I’m so sorry.” When I was twenty-six, I was asked how I
thought I’d find a husband if all I did was study. When I was twenty-eight, I
wore skirts to clinic, because I was told that female clinicians needed to look
“appropriately” professional. When I moved to my next job, I wore heels,
because the sound of my shoes on the floors and the way I walked commanded more
respect than a decade of post-secondary study. When I was thirty, I worked with
a nurse in the A&E that called me “Doc.” It was the gentlest way I’ve ever
seen to keep the patients from mistaking me for the nurses, because apparently
being petit, female, and younger looking equates to being a nurse. Regardless
of how you introduce yourself. When I was thirty-one, I was asked if I’d
completely given up on having children of my own. And when I was thirty-two, I
sat in the Dublin airport, waiting to board my flight home for the holidays,
and watched two politicians debate whether or not a dead body was allowed to be
treated as an incubator.
Ok. Thought point number one:
clinical uncertainty and ethics. I could not, if given all the time in the
world, recount the number of ethical landmines I’ve stumbled across in my
field. I am a paediatrician. I have worked in the maternity hospitals here in
Ireland, and do I have stories. I have worked in the paediatric hospitals, more
stories. And I currently teach. Our curriculum recently added ethics as taught
by the ethics department, specific to our subspecialty. It is apparent that
there are no hard and fast rules. I used to enjoy the intellectual stimulation
of debating these points in med school; I don’t anymore. Take, for example, the
rules of consent for children. Under the age of sixteen, the parent is the
person to consent for the child; this is, of course, ignoring the Gillick
Competence that remains untested in Ireland. Simple enough? A father can
consent for their child only if they were married to the mother at the time of
delivery or he legally adopted the child subsequently. Foster parents are often
not legal guardians and children remain wards of the state, or the birth
parents retain consenting rights in spite of multiple years of fostering.
Sometimes we have to send the Garda out to find parents of children brought
into A&E via ambulance before we can treat them; sometimes we have to treat
them before we can gain consent, because it’s considered a medical emergency.
But at half-four in the morning, with a drunk child that has a laceration, and
no one can find the parents, and the kid is refusing to give a blood sample,
and you have your consultant on the phone telling you what you ‘might’ be able
to do… Yes, I can absolutely see how three doctors ended up in a room debating
the 8th Ammendment.
We walk a fine line as doctors. We
base our decisions, our clinical judgment, on evidence, statistics, and
research, as well as past experience. I’ve looked at a child and known,
instantly, what’s wrong with them; I’ll never be able to explain how I came to
that conclusion. No, that’s not fair. I can explain it, but I’ll give you a
rational and logical outline of something that happened in my head, at a speed
that I didn’t even follow at the time. It’s intuitive. And it won’t stand up in
court. Percentages, numbers, clinical guidelines, those stand up in court.
Those are what we are expected to write in our charts. But at the end of the
day, there-in lies the conflict of patient advocacy. If the numbers suggest
that path A is the safest and most likely, yet experience or gut-feeling
suggests path B is what’s happening… Regardless of which path is chosen, if it’s
incorrect (and I have been wrong in both directions), it can leave you with
feelings of self-doubt at best, and land you in a coroners court at the far end
of the spectrum. In training, we are taught to expect uncertainty, but I don’t
think we’re always given the tools to manage it. Particularly when the
consequences of being wrong can (and rarely, but do) result in death. The fear
of litigation shouldn’t be the deciding factor in medical treatment, but I know
it can be. You can’t treat experience and you can’t teach judgment. [Brief side
rant about the lack of training due to understaffing and overworking of NCHDs,
NCHDs being pulled out of training early to fill jobs that they may or may not
be yet qualified for, consultants working with more junior and less numbered
NCHDs and expecting too much of them. The system is broken and it will fail the
population in many ways, more than just overcrowding, and uncomfortable ethical
debates.]
Thought number two: (as posed by
the current Master of the National Maternity Hospital) Why aren’t we hearing
more from our women about this [the ambiguity of the 8th amendment
and the necessity of “traveling”]? The number of women that travel from Ireland
to the UK in order to obtain legal and safe terminations is shocking and
desperate. And the immediate response was, “It’s time to start listening to our
women.” It is. It is well past time. And I think the way we talk about it is
part of the problem.
First, “Traveling.” Why do we have
a gentle term for the horrifying practice of exporting abortion to another
country? Let’s call a spade a spade, shall we? If Ireland wants to believe that
there is, “a clear blue line” for safe and legal abortion in the country, then
where is it? Fatal fetal anomalies are terminated in the UK for us. Anomalies
that are not compatible with sustained life are terminated in the UK for us. As
far as I can tell, the only non-exported terminations are those confronted in
maternal life-or-death emergencies (and some are not handled well, I’m talking
about Savita), and in threats to maternal health (and some are handled
extremely poorly, I’m talking about the C case and the Y case). We cannot
continue to export our shame. And we cannot continue to hide the truth of this
practice in euphemism and evasive statistics. As Dearbhail said, “If we’re not
letters, we’re numbers.”
Second, “Shame.” And this circles
round to the suggestion that deference in Ireland has shifted from the Catholic
Church to Law, though incompletely and perhaps in error. Why are these things
secrets? Why do we have this intrinsic sense of shame in the discontinuation of
pregnancy? Why do I have friends that dread returning to work after
miscarriage, because they don’t have a baby to show for their time off? Why is
the ability to produce a child still the pinnacle of what women are here for?
It’s not a law reason. It’s not a logical one. It’s a historical one. If a
woman is told that her baby will not live once it is born, why does she then
have to decide whether to continue to grow the never-to-be-born-alive fetus
until her uterus expels it (and take on all the possible risks and adverse
outcomes of that path) or to leave her country and enter into another health
service to terminate the pregnancy? Where is the logic? It’s certainly not
cheaper. Where is the compassion? This is violent. And where is the objection
to medical intervention coming from?
Third, “Time and Cost.” And this is
something I often wonder about. Is the lack of court cases, the lack of
publicity a result of the time-sensitive nature of termination? If you have
less than a month to come to such a heart-breaking decision and make
arrangements, is court really something that is in the forefront of someone’s
mind? Cost is a huge problem. As was questioned, who is going to pay the legal
fees from the case over Christmas? There didn’t seem to be any opposition, so
how did it get to that point? And from a purely pragmatic standpoint, babies
that are born with anomalies that are incompatible with life are very expensive
for the health service. There is financial cost, time cost, emotional cost, and
facing all of these, sticking your head up and making waves seems like one of
the last things a person would be looking to do.
Thought number three: Why did I sit
there and think that this talk was so very brave? I think everyone can admit
that discussions around termination are a challenge. From the difficulty in
seeking balanced representation in the media, to getting accurate clinical
information and keeping the discussion on the current and relevant topic, this
is the minefield. Dearbhail is right, this topic tends to bring out the worst
in people (on both sides). And sticking your neck out tends to result in swift
and ugly responses. I have been told I’m a bad Catholic for my views, I’ve been
told I’m a poor excuse for a woman, I’ve been told I lack compassion, I’ve been
told I’m not allowed an opinion because I’m not Irish, and I’ve been told I’m
going to hell. But let me be clear, my religion and spirituality steady my
ability to face life and death on a regular basis; my gender will never be
irrelevant, but only gives me more space for empathy; my compassion keeps me up
at night, has me staying late to treat patients (not for overtime pay), guides
my rational and treatment of patient, parents, and families; we live in an ever
expanding global community, don’t dismiss my thoughts for the sake of nearly
extinct mental homogeneousness; and if I’m going to hell for those things, then
I’m not sure I want that version of heaven. I know that this post will probably
get trolls. I’m not out to debate abortion right now.
What I do want to discuss is the
reticence to properly legislate termination. This is not something that can
continue to be brushed off, keep your head down and keep on keeping on because
it’s not been a problem yet. It is a problem. It’s a problem so severe that
doctors are afraid to listen to their own clinical judgment and evidence. It’s
a problem that had three doctors sitting in a room, hoping to get guidance that
was never forthcoming, hoping to avoid a jail sentence longer than rapists,
hoping to do what was right, but seemed counter to a Constitutional Amendment.
I want to discuss the fact that the debate, the legal discussion, the court
case, the entire situation was grotesquely absurd, and I thought (very
privately) also horrifyingly necessary. This case, ultimately, came out as
rather clear-cut, but it won’t be the last. There will be another that is
murkier and gut wrenching, that tests the legal shades of grey, that pits the
mother’s life against the unborn.
Pinch of prevention for a pound of
cure. Just because the situation hasn’t presented itself, doesn’t mean we can
ignore it. Quite simply, lack of preparation invites catastrophe. I’m not
saying we need to board up the windows and doors at the first signs of wind and
rain, but maybe we should at least put on a raincoat and pack an umbrella.
