Position: Legislation ToP

New amendments have been added to the legislation. Many we consider unnecessary as they are dealt with in other legislation, but some are very important for accountable, accessible health care. AACW has compiled a list of our recommendations in this easy-to-follow table: 

NumberSummaryAACW Recommendation
1.Change to title so it is apparent that it is about access to
healthcare not criminalisation.
Support
2.Introduce term ‘Access to Abortion’.Support
3.Replace ‘Female’ with ‘Pregnant’ to ensure
semi-trans inclusive language.
Support
4.State to pay for termination of pregnancy
only in case where there is a risk to life in sections 10/11.
No support
5.Delete lines 30-37 (pg.6) and lines 1-11 (pg.7)
to decriminalise abortion in line with JOC.
Support
6.Sanctions will not apply to a doctor
acting in good faith.
Support
7.Decriminalise a lay person helping another to terminate pregnancy illegally (not coerced, but outside the law).Support
8.Replace ‘not exceeding 14 years’ to ‘term proportionate to the offence’ to allow for a scale of criminalisation proportionate to the offense.Support
9.Remove term ‘not exceeding 14 years’.Support
10.Remove the office of a body corporate (replaced below).Support
11.Change to review from 5 to 3 years from implementation.Support
12.Specifics about the content of the review: barriers experienced; numbers still travelling; anyone unable to gain access; inclusion of women from NIand; recommendations of the Citizens Assembly.Support
13.Renumbering of sections.Support
14.Moving a section of the billNo position
15.Amendments to the health grounds: two doctors confirm that there is a risk to life or serious harm; the foetus is not viable and; termination will avert the risk identified or; the woman deems the risk to be unacceptable.Support
16.To add consulting with the woman post-12 weeks.Support
17.To delete ‘of serious harm’, leaving abortion on the grounds of risk to health.Support
18.Definition of ‘viability’No position
19.Change ‘avert’ risk to ‘reduce’ risk as a ground for abortion.Support
20.Change ‘avert’ risk to ‘mitigate’ risk as a ground for abortion (alternative to 19).Support
21.Renumbering sectionsNo position
22.Renumbering sectionsNo position
23.Allow transfer of patient care between doctors.Support
24.Allow transfer of care as soon as may be (alternative to 24).Support
25.Re: pg. 10, consultation with woman.Support
26.Repeat of 24.Support
27.Replace ‘examined’ with ‘consulted with’, to avoid physical examination at first visit.Support
28.Prohibition on abortion for race, sex, disability or health condition.No support
29.Provision for Dr. who is referred to act, provided original Dr. has certified.No position
30.Change ‘matter’ to ‘matters’No position
31.Removing the 3-day waiting period.Support
32.Start waiting period when appointment is first made.Support
33.Start waiting period when appointment is first made (alternative to 32).Support
34.Removal of the waiting period if this would mean the woman would exceed the 12 weeks limit.Support
35.Allowing transfer of care between doctors.Support
36.Moving reference to waiting period.Support
37.Analgesic medicine to be administered to the foetus.No support
38.Protection of foetuses born alive.No support
39.Section on reviews: remove ‘serious harm’ to match with proposed changes to health grounds.Support
40.Section on reviews: replace ‘avert’ with ‘reduce’ to match with proposed changes to health grounds.Support
41.Certifications process, tidy up from other changesNo position
42Recording for the purpose of monitoringSupport
43.Section on monitoring, tidy up from other changesNo position
44.Long insert on foetal ultrasound and auscultation of heart tone. States that: the above must be performed and women must be offered the opportunity to see/hear; woman must sign if she agrees/declines; proposes penalties for practitioners if they vary from this, with definitions of terms.No support
45.Parents must be informed in advance and supplied with certification (various lengths of time proposed), can be waived by high court. Includes some definitions.No support
46.Very long insert on informed consent. States that except in an emergency, information must be provided to woman including: the methods of TOC; risks of TOC; information on the development of the foetus; alternatives to abortion; reversibility of abortion via medication; information supports for parenthood (if >20 weeks gestation) with this to include anaesthesia. Sanctions to apply if not complied with.No support
47.Conscientious objection for doctors, nurses and midwives (in hospitals).No support
48.Add pharmacist to list of those who can object.No support
49.Add students to those who can object.Support
50.Recording of CO events with Minister, and, explicitly stating that institutions/body corporates (hospitals) cannot object if in receipt of public funding.Support
51.Tidy up in line with earlier proposed changes.No position
52.Add student midwives to the description of midwife.Support
53.Add other possible practitioners to the description.Support
54.Definition of Pharmacist to be included in legislation.No support
55.Add students to list of practitioners.Support
56.Block on institutional conscientious objection.Support
57.Criminalising support and allies.No support
58.Defining responsibility when offender is an institution.Support
59.Dignified disposal of foetal remains.No support
60.Remove reference to profiteering.Support
61.Tidy up in line with earlier proposed changes.No position
62.Tidy up in line with earlier proposed changes.No position
63.Remove requirement for patient to be ordinarily resident in the state.Support
64.Tidy up in line with earlier proposed changes.No position
65.Tidy up in line with earlier proposed changes.No position

Abortion Access Campaign West Position Paper, Sept 2018

Abortion Access Campaign West (AACW) is a women’s collective based in Galway set up to lobby government on legislation and ensure that abortion access is widely available in the West of Ireland. Our position paper on the proposed legislation (General Scheme of a Bill Entitled Health (Regulation of Termination of Pregnancy) Bill 2018) is focused, in particular, on ensuring the best care for women/pregnant people in the West of Ireland.

General Comments

The wording of the draft legislation suggests that termination of pregnancy (TOP) is wholly a medical/legal matter and there is no sense that it implies an obligation to consult or involve the woman/pregnant person in the decision making process. We believe that the emphasis in the legislation should express a woman/pregnant person centred approach.

A TOP will become a legally available medical procedure within the terms of the legislation; given the historical attitude towards women’s health in this state, it is important that the emphasis is on provision of a health care service, where the woman/pregnant person’s needs are the priority throughout the process.

Beginning with Head 4(1) we suggest that the wording is changed from ‘A termination of pregnancy may be carried out in accordance with this Head’ to ‘a woman/pregnant person may terminate a pregnancy in accordance with this Head…’ and that, where appropriate this emphasis is carried throughout.

We also suggest that there is clarity on whether there are any citizenship requirements under Head 1.

A doctor’s appointment should be available as a matter of urgency for a woman/pregnant person requiring a TOP and repeat visits should not be necessary.

The woman/pregnant person should have the choice as to which method is used to terminate, i.e. medication or surgical.

Necessary facilities should be available locally and within the time limits. A supportive facility to complete a medication abortion should be available if requested by the woman/pregnant person as there may be personal reasons inhibiting a home termination.

It should be an offence to hinder a woman/pregnant person from accessing an abortion by deliberately providing incorrect or misleading information.

It should be an offense to impede access to facilities providing abortions by protesting within a stated distance of such a facility, by displaying graphic images or offensive messages, or using abusive or threatening language.

Any person who refuses or fails to co-operate with the provisions of the legislation e.g. conscientious objectors who refuse to refer or purposely cause delay, must be held accountable.

Abortion should be regarded as a medical procedure like any other with the same rights and responsibilities attaching to service users and providers.

The outcome of reviews must make reference to after-care and the well-being of the individual post-review.

Where terminations are refused in the State, information on services outside the State should be readily available and accessible.

Ease of access to the services must be a priority. We are particularly concerned that women/pregnant people in the West of Ireland are not obliged to travel long distances to access services.

Information on location of services and on the procedures involved needs to be accessible, particularly for rural dwellers, who may have a more limited access to sympathetic doctors.

The draft legislation dates the pregnancy from the first day of the last menstrual period (LMP). We believe dating should begin at fertilisation which is two weeks after 1st day of LMP. Ovulation can occur up to 18 days post 1st day of LMP.

Provisions should be made by the HSE to facilitate access to TOP services for women/pregnant people in Northern Ireland.

Definitions

Abortion:We believe ‘intended to end a pregnancy’ should be usedin place of ‘intended to end the life of the foetus’. The latter definition may contribute to stigmatising the procedure.

Woman: Women/pregnant person should be used throughout the legislation and taken to mean any person capable of being pregnant of any gender or age

Health: The most up to date definition of health as laid down by the WHO is our preferred definition. This states that: ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ (‘WHO | Constitution of WHO’) We recommend that the definition of health be indexed to the WHO definition.

Heads 4 & 5

The term ‘appropriate medical practitioner’ should include nurse practitioners, midwives or other healthcare professionals with appropriate expertise.

‘Risk to life or serious risk to health’ needs to account for the physical, mental and emotional health of the woman/pregnant person. There needs to be clarity and uniformity in the definition. AACW recommends the aforementioned WHO definition.

Certification should happen after thorough consultation with the woman/pregnant person and include a self-assessment of the woman/pregnant person’s risk to life and/or health.

The viability of a foetus could be interpreted variously by different medical professionals. Their needs to be a standard, clear guidelines.

We need a clear interpretation of what constitutes a ‘risk to life’ ‘serious harm to health’, and the legislation should state that the woman/pregnant person’s own assessment of the risk is taken into account.

Head 6

As in Heads 4 and 5, the legislation should state that the decision to terminate is made in consultation with and having regard to the opinion of the woman/pregnant person.

Head 7

Availing of an early TOP is at the individual’s request and the wording of this section should read along the lines of ‘where a woman/pregnant person decides to avail of a termination in early pregnancy and a medical practitioner confirms the length of gestation and there are no adverse health implications, medication for the termination of pregnancy shall be prescribed’.

Dating the pregnancy should begin from fertilization and not LMP. We believe dating should begin two weeks after 1st day of LMP. Ovulation can occur up to 18 days post 1st day of LMP.

Weeks of pregnancy should be calculated using routine, straightforward, and prompt methods unless there are valid medical reasons for more comprehensive examination.

The 3-day waiting period is unnecessary and should be removed or at the very least begin from the date of first contact with services (phone call, email, face to face contact etc.).

Head 8

If a review is sought, the doctor should have to state the basis for refusal. This should be discussed by the doctor with the woman/ pregnant person seeking the termination.

Specific criteria for informing the woman/pregnant person that a TOP has been denied is required including the length of time to do so, means of communication, and the specific reason(s) for refusal.

Written notification should be given on the same day as the decision is made.

It should be the right of the woman/pregnant person to seek a second opinion.

There is no stated timeframe for this part of the review process.

The review process is needlessly cumbersome and protracted in what can be a time sensitive situation.

The HSE should provide support where the woman/pregnant person is making an application and going through the review process.

The form of application should include the option to state reasons for seeking a termination and to challenge the basis for the refusal.

Heads 9 & 10

The review panel should include psychologists and psychiatrists, as ‘serious risk to health’ includes mental health under the WHO definition.

The woman/pregnant person who is the subject of the review should be present and represented. Associated costs should be made available.

Other health practitioners such as midwives should be included on the panel. Review panel needs to include non-medical health professionals e.g.: social workers, civil/human rights/family law lawyers and the panel needs to be gender balanced and guided by the ethics of care.

As stated above, the review process is needlessly cumbersome and drawn out, particularly in respect of circumstances where time is a relevant factor.

We are very concerned at the lack of the woman/pregnant person’s right to engage with the review as of right and to present their own assessment of their situation.

Willthere be monitoring of decisions to ensure they are being made in an unbiased manner?

Head 11

Overall the review process is alienating and not woman/pregnant person centred. It must accomaditate the different needs and circumstances of those who use it. For example minors/island and rural dwellers / Traveller / low income / disability / homeless / direct provision / LGBT/ undocumented people may find it difficult to engage with.

A maximum time frame for the arrangement of the TOP should be set out.As noted under Head 10, the woman/pregnant person should be informed in writing the same day as the determination is made.

The woman/pregnant person is only informed that a decision has been made. It doesn’t appear that the grounds for the decision are conveyed to her, which they should be.

The process is time sensitive yet there is no time specified within which the woman/pregnant person is informed of the decision.

What accountability exists if the review panel goes outside time for a termination to occur?

Head 12

The woman/pregnant person must inform the review board that she/they wish to be present and heard. Her/their right to attend should be an inherent part of the process. She/they should also have the right to be supported by a partner, parent, friend, or other advocate.

The documentation examined at the review is that which the committee requests, it does not include any documentation that the woman/pregnant person might wish to include.

The original medical practitioner who triggered the review does not appear before the committee to explain his/her/their decision and this places an added burden on the applicant.

The executive ‘may’ bring proceedings against a doctor who does not comply. This wording would not appear to place a very heavy burden on a reluctant doctor.

The review committee should convene in the locality of the woman/pregnant person or funds should be provided to help her/them travel to the review.

Head 13

What are the remedies in cases of wrongful delay or denial of abortion? What accountability exists?

The processes of certification and the operation of reviews needs to be accountable to service users. This must be holistic and integrated which means putting in place an appropriate system of consulting with pregnant women/persons and documenting their experiences of the review process (Users advocate groups).

Head 14

The issue of consent to medical treatment, especially in relation to pregnancy, needs to be re-examined in the aftermath of the repeal of the 8th amendment.

Should there be reference to changing/updating/rendering compatible HSE consent guidelines and procedures during pregnancy?

Can the concept of consent be elaborated on in the definitions to include a nuanced explanation of consent and informed consent?

Are changes in the law necessary in relation to consent where a person lacks capacity to give informed consent? Does the Assisted Decision-Making (Capacity) Act 2015 have any bearing on TOP? ((eISB))

What is the legal situation for vulnerable adults and minors? Is there a role for parents?

Head 15

There is no mention of institutions providing maternity services and their ethos.

There needs to be freely available information (register?) of doctors who will prescribe pills for medication abortion. There is a danger that unless the service is seen as a normal part of healthcare it will become stigmatised thus affecting access.

Where medical practitioners are listed as Conscientious Objectors alternative provisions need to be in place. The lack of local services could pose significant difficulties, particularly for pregnant women/people living in rural areas. In cases where the woman/pregnant person has to travel outside their locality, financial assistance should be available to help defray the costs involved.

The process of completing the referral and the appropriate timeline for this is not clear enough.

Head 16

Clarification is needed on the information compiled by the review committee in respect of an application.

Will the applicant have access to the information as part of her/their own medical record?

If a further TOP is sought by the applicant, will this information be available to a future review panel?

What are her/their rights in relation to the use of this information? For example, could it have a bearing in a situation where she/they needed a second termination?

Head 18

Excellent pre and post abortion care for pregnant persons should deem this Head obsolete and unnecessary.

Head 19

As noted under Definitions, the phrase ‘end the life of a foetus’ should be replaced with ‘end a pregnancy’.

It should be clear that there is no legal prohibition to travelling outside the state for a TOP, whether or not a TOP was sought in the state.

There needs to be clarification as to whether it will be a criminal offence to assist someone with having a termination.

As this is healthcare legislation, offences should be dealt with under criminal law legislation.

Works Cited

(eISB), electronic Irish Statute Book. Electronic Irish Statute Book (EISB). http://www.irishstatutebook.ie/eli/2015/act/64/enacted/en/html. Accessed 18 Sept. 2018.

General Scheme of a Bill Entitled Health (Regulation of Termination of Pregnancy) Bill 2018. 2018.

‘WHO | Constitution of WHO: Principles’. WHO, http://www.who.int/about/mission/en/. Accessed 18 Sept. 2018.

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