The Protection of Human Life Bill, 2013: Your Questions Answered.

The General Scheme of the  Protection of Human Life Bill During Pregnancy Bill 2013 was published last night. The General Scheme is not a draft Bill but it gives us a sense of the likely content of the Bill and of the rationale for the proposed provisions. This is a quick overview of some of the most important questions which it presents, with links to the answers which we have provided on this blog in previous posts. Other members of HRinI may add to this with their own observations in the coming days. Your comments and questions are very welcome.

Have the Floodgates Opened? No. This is legislation for X, 21 years later. It is not a revolutionary Bill. Beyond the Scheme, abortion – whether procured by a doctor or by the woman herself – remains a criminal offence, albeit the penalty will change from life imprisonment to a fine or a maximum 14 years in prison. The proposed Bill does not, and indeed as Laura Graham and Fiona de Londras explained,  cannot extend Ireland’s abortion scheme beyond the scope of X. The Scheme emphasises that it applies only to the minority of cases. The Scheme makes significant provision for recording and reporting the basic details of terminations carried out under it, which will lend welcome transparency to this area of law. Abortions will not be permitted in Ireland in cases where there is a risk to the physical or mental health of the mother eg as might happen in cases of incest, rape, or the non-viability of the foetus. Women in that position will be at the mercy of the ‘constitutional right to travel’. Arguably, the proposed legislation does not go to the full extent of what is permitted by X in that it does not make provision for the termination of pregnancy where the foetus is not viable. On the possible justifications for including such a provision see Ivana Bacik here and Jennifer Schweppe and Eimear Spain here.

Will the Legislation Affect Assisted Reproduction? The Bill suggests that the Government is willing to provide a legislative definition of ‘unborn’. Embryos pre-implantation do not fall within the scope of the Scheme. ‘Unborn’ includes a foetus in the process of being born, and no term limits are included.

How Many Doctors Will Be Involved in Clinical Assessment? Appropriate clinical assessment triggers the constitutional right. One doctor may provide an abortion without further permissions from colleagues if the mother’s life is at immediate risk and an abortion is immediately necessary to save it.  Otherwise, a woman may refuse an abortion, but she cannot obtain one without the permission of multiple doctors. Where there is no immediate risk to life, the woman who obtains an abortion under the proposed scheme will have been examined and certified by multiple doctors; 2 (an obstetrician/gynecologist and one other of a relevant clinical speciality) where the mother’s life is at risk due to physical illness and 3 (one obstetrician/gynecologist and two psychiatrists) where the risk arises from the mother’s suicidal intent. GPs will be consulted but will not have decision-making powers. The doctors must jointly certify their opinion. The Taoiseach today said that they must be ‘unanimous’, which raises issues as to whether a single doctor of two or three can effectively block access, compelling the woman to appeal or – if she is able – seek termination elsewhere.

What About Suicidal Women? Suicidal women are to be included in any legislation, despite opposition from within Fine Gael. As  Fiona argued here,  the Oireachtas cannot exclude suicidal women from the legislation and still meet its constitutional obligations.  (See Paul Brady here for a counter-argument). However, suicidal women are to be subjected to a separate scheme to women whose life is at risk for purely physical reasons. Fiona explained why this is unjustifiable here.  Clare Murray explained here. that the provision for multiple doctors to ‘certify’ the risk to life is unusual and controversial even a mental health context (and of course, this legislation will apply to women who are not mentally ill), but the Taoiseach seems convinced of the need for a demonstrably more rigorous standard given the ‘subjective’ nature of the assessment of suicide risk. The mooted requirement for the involvement of perinatal psychiatrists has been removed. The application of this scheme could subject the woman to multiple examinations as it is not required that the three doctors examine her together or at the same location. The Scheme leaves it to the professional bodies to provide guidance on standard medical practice, referral pathways and so on. Real concerns are emerging around the participation of psychiatrists in this process as one significant group of psychiatrists have refused to participate in any form of assessment panel while another minority group actively campaigned for the exclusion of suicidal women from the legislative scheme. There is, and can be, no suggestion that a woman who is not otherwise mentally ill can be detained until a decision is reached as to her entitlement to abortion.

Will this Scheme Provide Clarity to Doctors? Doctors acting as gatekeepers to a woman’s constitutional right are asked to determine ‘in good faith’ that there is a ‘real and substantial risk to the life of the mother’ and that in their ‘reasonable opinion’ that risk can only be averted by a termination. See John O’Dowd on the difficulties in assessing ‘real and substantial risk’ here. While the Scheme makes clear that an abortion is permissible even where the risk to the mother’s life is not ‘immediate’, real difficulties in applying the test remain. In a case mirroring that of Savita Halappanavar, access to abortion would still depend on medical assessment of the risk, albeit the Scheme formalises the process of assessment.  However, the Scheme explains that it would have been difficult to provide in legislation for every one of the complex and unpredictable circumstances in which a risk to the mother’s life might arise. The Department of Health will work with the relevant professional bodies in developing guidelines for members.

What if a Woman is Refused an Abortion? The HSE will establish and maintain a medical review panel to which such women may appeal. Members will be nominated by the professional bodies. Members of the panel will convene as an independent committee on a case by case basis to review refusals in cases of risk arising from physical illness and risk arising from suicidal ideation. The committee will have two members in the latter case (an obstetrician/gynecologist and a specialist) and three members (an obstetrician/gynecologist and two psychiatrists) in the former. Thus a woman who obtains an abortion in Ireland may indeed have been subject to the judgment of six doctors. This appeals process is the Scheme’s effort to establish the appeals framework needed meet the requirements of the A, B and C v. Ireland judgment. The woman may apply for an appeal herself, or it may be made on her behalf with her consent. The committee will be competent to review the reasons for the decision and the relevant evidence, and to fulfill the requirement of A, B and C v. Ireland should provide the woman with an opportunity to be heard. It shall convene within 7 days of application and reach a decision within 7 days. If a medical emergency develops such that there is an immediate risk to the mother’s life, the emergency provisions will apply and there will be no need to await the outcome of the appeal. No third party may use the scheme to challenge a decision to provide an abortion. Again, the decision must be jointly certified.

Are There Too Many Obstacles In Women’s Path? Humiliation, fear and other dignitary harms are not in themselves breaches of a woman’s European Convention Rights. What we need to look out for in the operation and enforcement of the scheme are chilling delays and uncertainty; the systemic placing of obstacles in a woman’s path to undermine her access to her rights. While the appeals mechanism indicates a 14 day time limit for decision-making, concern has been expressed about rural women’s timely access to doctors qualified to certify their entitlement to abortion under the scheme in the first place. It may be, nevertheless, that women who are entitled to abortions under the scheme will prefer to travel outside the jurisdiction rather than submit to the certification and appeals process.

Can Doctors Privilege the Interests of the Foetus Over the Interests of the Mother Under the Proposed Law? The Constitution already limits the rights of the mother by reference to those of the foetus. However, there are a number of important points here.

First, the legislation imposes a duty on medical practitioners ‘to preserve the life of the unborn insofar as possible’, and this may include efforts to deliver a viable foetus. This does not mean that doctors should adopt an attitude of hostility or skepticism in assessing the risk to the mother’s life (the ‘good faith’ decision) but it will legitimately affect doctors’ choice between abortion or other medical procedures compatible with the right to life of the mother (the ‘reasonable’ decision).

Second, a doctor may exercise the individual right of conscientious objection to participation in an abortion. I discussed this issue at length here. Under Medical Council Guidelines a doctor exercising this right should refer the patient to an alternative practitioner.  An action for abuse of this provision (for instance where a doctor did not declare his conscientious objection and refused to certify a woman without explaining that this was the reason) should lie in negligence, if appropriate harm results. It would be preferable, in my view, if the legislation made explicit provision as to conscientious objection rather than relying on the Medical Council Guidelines, which are brief and somewhat vague.

Finally , a woman refused an abortion will have a right of appeal as set out above. It is especially important that the appeals mechanism is seen to be sufficiently independent and impartial to inspire public confidence.

 

The Protection of Human Life Bill, 2013: Your Questions Answered.

Abortion, Unease and Citizenship in Ireland.

This is a cross-post from Inherently Human: Critical Perspectives on Gender, Law and Sexuality.

A great deal has been written about the recent developments in Irish abortion law. Most readers will know the basics. The Eighth Amendment to the Irish Constitution, as interpreted in a case famously known as X, provides that a pregnancy may only legally be terminated in Ireland if: (i) there is a risk to life (as opposed to the health) of the pregnant woman; and (ii) as a matter of probability, that risk to life can only be averted by termination of the pregnancy.  In all other events, Irish women may and do avail of their constitutional right to travel, and most often seek abortions in the UK, often at significant personal cost, or use medication purchased online. (Although the purpose of the Amendment is to ‘balance’ the rights to life of the pregnant woman and the foetus, women who are carrying foetuses which are not medically viable are habitually denied abortions in Ireland, even though the state itself argued in D v. Ireland before the European Court of Human Rights that such a foetus does not necessarily enjoy Eighth Amendment rights.) In the past year, three difficulties with the constitutional regime (always a matter of unofficial knowledge) have emerged into public view.

  1. The European Court of Human Rights in A, B & C v. Ireland held that Ireland must end the 20-year delay in legislating for the constitutional right to abortion because the delay in legislating has had a ‘chilling effect’ on doctors’ ability to assess women’s entitlement to access abortion in Ireland (for further details on the challenges of legislation, see a humanrights.ie blog carnival  here, and see a recent conference at UCC here). The Government formed an Expert Group to examine options for legislation and its Report was published last November. Subsequently, the Oireachtas held hearings on the implementation of legislation in which several representatives of the medical profession confirmed their desire for legal clarity. The Government has indicated that the ‘Protection of Maternal Life’ Bill is on its way in the summer.
  2. In the case of Savita Halappanavar, two of the costs of the Irish abortion regime have been laid bare. The first is the entanglement of religion and law which undergirds that regime. The second, which appeared from the inquest into Ms. Halappanavar’s death, is the fact that this regime both generates confusion on the part of doctors and, as far as several leading medics are concerned, requires doctors in cases where the woman does not present as at immediate risk of death to engage in a sort of  ’brinkmanship’, waiting until she is sufficiently ill to earn her constitutional rights.
  3. This week, there has been a great deal of discussion about what legislative provision should be made for abortion by suicidal pregnant women. There has been some suggestion that members of Fine Gael (the dominant partner in the coalition government) would require suicidal women seeking an abortion to be assessed by six doctors; two obstetricians and four psychiatrists of which one should be a perinatal psychiatrist. The assessment would take place in two stages – an initial certification and a review, presumably with some provision for appeal. This proposal is at odds with the Expert Group Report, which had suggested that, at most, two psychiatrists and an obstetrician should be required for this purpose, and even then cautioned against the risk of unnecessarily stigmatising mental illness. A leading Irish psychiatrist has called the proposal unworkable and abusive.

The terms of the Protection of Maternal Life Bill involve nothing less than Irish women’s citizenship. Campaigns such as Action on X, Doctors for Choice, and others represent the efforts of political coalitions to take the stage of citizenship, to contest the assumptions which have led us to this dreadful constitutional framework, and to write a law together which would treat our bodies and our voices otherwise. I want to say a little about what that challenge entails, particularly as it relates to political constructions of the suicidal woman.

In a recent article, ‘Civic Universalism and Its Internal Exclusions’ Etienne Balibar redoubles over his earlier work to point to a fundamental tension in modern citizenship. Citizenship promises equal access to the means of political transformation; to the public sphere. It promises that we shall be more than the servants of pre-established authorities. It promises to replace the vertical relationship with the sovereign with an immanent relation to the law, so that we – in community with others – shall be law’s authors more than its subjects. It says that we deserve nothing less because we are human; because the power of citizenship reflects the essential capacities which derive from our humanity. This is the promise of subjectivation. It is every citizen’s endeavour, and it is the endeavour which will mark the bloody Irish public debates of the coming summer.

At the same time, the subjectivation which citizenship promises is shot through with old obligations and demands for subjection. We become citizens in relation to other citizens. Our emergence as citizens is dependent on fellow citizens seeing us and judging us as such. The reality of our world is that forms of discrimination and oppression re-emerge in our relations with one another. These require our subjection, exclusion, and obedience. That is the experience of Irish women under the abortion regime (see an excellent post from feministire here). The excluded are ‘protected,  cared for, or “minorized,” (see the prominent pro-life Irish psychiatriast Patricia Casey here, arguing that suicidal pregnant women require protection and ’care’ ) but also punished, segregated, relegated, barred  from access to … exchanges, communities, and  recognitions’ core to citizenship. So, for instance, in Ireland, our Constitution – a legal regime premised on equal access to the freedoms, capacities and rights of citizenship – suppresses via the Eighth Amendment the rights claims of pregnant women on the basis of their purported natural difference.  Some of citizenship’s internal exclusions are more difficult than others. Those forms of subjection that coalesce around what Balibar calls the ‘anthropological differences’ – such as sexual difference – which are considered constitutive of the human generate perhaps the most violent exclusions, because they both call into question our full citizenship and our humanity (consider Praveen Halappanavar’s coupled observations that his wife’s experience before her death was ‘inhumane and barbaric’ and that ‘you lose your rights basically when you are pregnant in Ireland’).

But how do we understand the task of undoing the entrenched internal divisions of citizenship? Balibar has always argued that the task of politics is to re-take citizenship in all its potential. Subjectivation has only been possible by engaging old subjections, and yet subjectivation is always threatening to collapse into new subjections; this is an antinomy of citizenship. (Consider how the same Fine Gael politicians who applauded themselves on transcending the patriarchy of the Magdalene laundries fight now for the patriarchy of the imminent ‘Protection of Maternal Life Bill). So feminists and others, in claiming citizenship, must always be prepared to critique its internal divisions, to commit ourselves to a process of ‘revolution against the revolution’, of insurrection alongside constitution. Balibar provides some hope by reminding us of the fragility, contradiction, and contingency of anthropological difference. This is where the possibilities of resistance from the inside lie.

Balibar argues that anthropological differences, though impossible to dismiss are also impossible to define; they can neither be ignored nor stabilised. Attempting to define them entails inevitable and impossible struggles over definition, control, and visibility. Following Foucault, (and in a discussion which is markedly relevant to the current Irish debate on ‘suicidal ideation’, taking place as it does against a law which criminalises abortion) Balibar charts how an exclusion core to citizenship coalesces around the notion of the normal. The normal is defined, across multiple institutions, through the negation of mental pathologies and deviant criminal behaviour. These institutions – medical, penal, juridical, and others – distinguish among and judge between individuals, classify them, judge their characters, and distinguish between different forms of deviation from the norm. Psychiatry and law are keen collaborators in this ambivalent enterprise; Balibar notes how doctors become experts or ‘judges judging before a judge, who provide pre-judgment’; determining whether the subject assessed is a criminal or some other deviant personality who must be dealt with otherwise than by law.  And Balibar also notes, following Foucault, that these aspects of judgment – particularly legal judgment – may concern the entire citizenry, insofar as they instantiate obsessive attempts both to ‘defend the security of the society’ against the abnormal and to perform a collective introspection; trying to understand who ‘we’ are and to make human behaviour intelligible to ‘us’ (in terms, of course, which reassure ‘us’ that we are not abnormal like those ‘others’).

But Balibar emphasises that the adjudication of normalcy is a difficult obsession. The normal is ambiguous, and is necessarily destabilised by every attempt to assess it. In particular, subjects do not always lend themselves to pre-ordained categories and binaries; they do not behave as ‘we’ would ideally have them behave. For instance, Balibar argues that under liberal politics, the subject can be mad or criminal, but not both – perhaps the very binary that the X ‘psychiatric’ provision puts into play. Those who find themselves ‘out of place’ or emerge into a space where they do not belong Balibar calls ‘foreign bodies’. Attempts to incorporate them (or recuperate them) within the frameworks of knowledge/power which constitute the ‘normal’ must develop profound and unsettling contradictions; indeed, insofar as ‘anthropological difference’ is at stake, these contradictions go to the core of our sense of the human as much as of the citizen. (Ireland has had so many ‘foreign bodies’ to contend with in the politics of abortion, so many public appearances of women who do not fit the category either of the pure victim of ‘madness’ or the strategic criminal who would destroy a child for selfish reasons.)

How can a feminist politics of citizenship make the most of the ‘foreign body’? Foreign bodies may be made to appear ‘monstrously’ inhuman when subjected to the process of judgment. But Balibar insists that it is also possible to identify the ‘foreign body’ with the absolute or ‘arch’ human. ‘No being is more human or…more clearly embodying the “destination of the human”, than a criminal, a madman, a stranger…a jealous or hysteric woman…[T]aken together…all these singularities are the majority, the quasi-totality of mankind. They push the bearers of the model of the human… towards the margins’. Anthropological differences appear less ‘natural’. The sites of normality/abnormality become ‘impossible to locate’. They shift places and change configurations. This realisation makes the simple, positive exclusions which undergird citizenship impossible. Balibar argues that we can bring this sense of contradiction to bear on subjectivation. Remember that we become citizens in relation to one another. Suppose subjectivation can be suffused with a sense of the unease which the foreign body brings with her, so that in our relations with others we are all less certain of our own humanness and thus of our entitlement to judge, exclude, or protect under law; so that we are all irreducibly uneasy? (As I was writing this piece, the news came that the College of Psychiatry in Ireland has said that its members will not participate or ‘collude’ in the compulsory assessment of suicidal women seeking an abortion. Its members refuse to be the country’s ‘social police’. Isn’t this the appearance of the uneasy subject who refuses to participate in exclusionary judgment, and in so doing at least temporarily decommissions a process of subjection? How many other Irish people are slowly finding ways to manifest a similar unease?).

Abortion, Unease and Citizenship in Ireland.

Abortion, Resistance and the Politics of Death and Grief.

In recent months, spurred on by the judgment of the European Court of Human Rights in A, B & C, by the 2011 observations of the UN Committee Against Torture, and by Ireland’s Universal Periodic Review, we have seen a significant push towards legislation ‘for X. To this end, in February, Clare Daly TD introduced a Private Member’s Bill in parliament, which was debated and rejected in the Dail today. For its part, the government has appointed an expert group, chaired by Sean Ryan,  which will report on the possible legislative implementation of A, B & C in the summer (see the IFPA’s detailed critique of this strategy here). The majority of TDs speaking today seemed open to the proposal to legislate for X in principle, albeit they did not support this specific Bill. It may be that we are on the cusp, finally, of some legislative movement on abortion in Ireland.

Continue reading “Abortion, Resistance and the Politics of Death and Grief.”

Abortion, Resistance and the Politics of Death and Grief.

Committee Against Torture Observations Published.

As several newspapers have noted today,  the UN Committee against Torture has released its Concluding Observations for Ireland (all documents are available here). This is the Committee’s response to Ireland’s first periodic report. Fiona detailed the core issues on which the Committee was expected to focus here. We hope to have fuller posts on some of these issues in due course, and of course, welcome guest commentary from others researching in relevant areas.

Continue reading “Committee Against Torture Observations Published.”

Committee Against Torture Observations Published.

Irish abortion law's ‘waters about to break'?: Daly on A, B & C

HRinI is delighted to welcome the second in a series of expert guest posts on the decision in A, B and C v. Ireland. This post is by Dr. Brenda Daly of the Socio-Legal Research Centre at Dublin City University.

The decision of the European Court of Human Rights (ECtHR) in A, B & C v Ireland last week recommending that Ireland introduce legislation to establish an ‘accessible and procedural framework’ regulating when abortion is legally permissible cannot be described as radical or even controversial. The ECtHR effectively rubberstamps the status quo regarding the right to abortion in Ireland, and this decision could be described as an international sanction of the proposal for legislation to effectively implement Article 40.3.3 of the Constitution (which was initially put forward by the Supreme Court in the Attorney General v X in 1992; the Constitution Review Group in 1996 and subsequently the Interdepartmental Working Group Green Paper on Abortion in 1999).

  Continue reading “Irish abortion law's ‘waters about to break'?: Daly on A, B & C”

Irish abortion law's ‘waters about to break'?: Daly on A, B & C

Update on A, B and C v. Ireland

While everybody at home was paying attention to the budget, the Irish Times reports that Strasbourg saw the opening day of A, B and C v. Ireland. The webcast of this morning’s hearing is here and Channel 4 News includes a short report including footage of today’s proceedings and an interview with Ruth Fletcher of Keele University here.

There are two main elements to the state’s defence of the Irish legal regime on abortion. First, the Times reports that the Attorney General Paul Gallagher SC  (left) insisted that the country’s abortion laws were based on “profound moral values deeply embedded in Irish society”. Mr Gallagher suggested a broad Irish allegiance to the law as it stands when he said the country’s legal position on abortion had been endorsed in three referendums, as well as being safe-guarded in protocols attached to the Maastricht and Lisbon treaties. However, it is also true to say that the three referendums, while they retained the prohibition on abortion, have steadily narrowed its scope since 1983 while a 2007 Irish Times mrbi poll indicated that Irish attitudes around abortion are considerably softer than the AG would allow.

Continue reading “Update on A, B and C v. Ireland”

Update on A, B and C v. Ireland