30 November 2012

Press Freedom: serving an Ace

Let’s say that something unpleasant was written about me in the press, and not just unpleasant but untrue. I don’t like it, and I sue the newspaper and win; I win financial compensation, and get some sort of printed apology (which is probably well hidden).

I’m financially compensated for my hurt; yet there is the lingering doubt in the public mind that the press wouldn’t have written about me unless there was something to go on, the “no smoke without fire” argument; and of course “mud sticks”.

And although I’m richer now, really, I’d prefer to have the perpetrators in the pillory and throw rotten eggs at them.

But this isn’t going to happen; to sue for libel you need to be rich, or have lawyers risk an action on a “no fee, no win” basis. I doubt if any would really want to help me, and I’m not rich, certainly not rich enough to risk loosing a suit. So, I’m effectively powerless.

Anyway, why should I have to chase the perpetrators? I haven’t done anything wrong, yet it’s up to me to take action. If I do nothing, they aren’t going to apologise, to retract or to pay compensation. The “ball is in my court”, but I didn’t ask for the serve, and I can’t return it: it’s an “ace”.
Yet the press does have a code of conduct, one which covers what they should do and what they should not; and it seems to be very sensible and reasonable. The problem is that it’s been ignored by those who think they can get away with it. It’s not the code that’s lacking, it’s the enforcement of it, the compliance.

An aside: the code wouldn’t approve of illegal methods of news gathering, or paying for stolen goods. Yet the MPs and their amazing expenses only came to light through the Daily Telegraph — not my choice of reading material — obtaining such stolen information by paying for it. I don’t know of any similar investigation where the results have depended on hacking phones or intercepting emails; an investigation turning over the murkier, perhaps criminal, aspects of life. But I could appreciate that in such a case, the ends could well justify the means. If it’s illegal to illegally hack phones and emails, there must be an implicit but unstated legal use of such activities. (Of course, hacking phones of “celebrities” and suchlike for purely salacious, lubricious ends is in no way comparable. Who doesn’t have feet of clay?)

If compliance is the real problem, how then is it to be enforced? Lord Justice Leveson favours self-regulation, which is “underpinned” by statute, and which seems to have a second regulator checking on the first. Unsurprisingly, this is being spun as an infringement on a “free” press, as government control of the press. He offers sticks and carrots to try to ensure that all newspapers will agree to it — but he recognises that membership cannot be enforced, however desirable; and he recommends that the “freedom of the press” be enshrined in legislation.


What would life for the press be under a “statutory regulator”? I can’t offer a very exact parallel, but I can suggest how it could work.

Before the Medical Act of 1858, medicine was an unregulated profession, attracting more than its fair share of charlatans, snake oil merchants and the like. The Act set up the General Medical Council which required doctors to be registered with it, and which had the power to censure doctors, and to strike them off. The GMC is an example of “self-regulation”, where its formation is statutory, but it’s actions are determined by itself.

The GMC’s remit has been updated through the years; medical Royal Colleges through their charters also have regulatory powers, though these are essentially devolved to the GMC.

The GMC is a “regulator” established by statute; its activities include publishing codes of conduct for doctors. But the government does not interfere with its work; the government’s activity is limited to introducing new legislation to “update” the GMCs functions.

Almost all doctors in the UK are employed in the NHS, in “Trusts” or general practitioner groups. These are not free agents; they are required, for example, to accede to “best practice”, as defined by NICE; and to be aware of financial pressures. Doctors in NHS practice are not “free agents”, they cannot offer whatever treatments they like — even if, in the past, this was the case. Yet most of them would accept the NICE guidelines, though financial pressures may require them to act to ration treatment, something that can be very difficult, yet is largely outside of “regulation”. Within the NHS there are various ways in which practice (or personal relationships) suspected of being substandard, ineffective or harmful can be investigated. This range of possibilities includes an informal visit from the “three wise men” to a formal, full scale enquiry.

These problems are not found in private practice, where the only regulation of the individual is through the GMC. (Of course, there are regulations around the safety of installations in much the same way as a printing press would be subject to Health & Safety regulations.)

There are two main, important ways in which this “statutory regulation” differs from that suggested for the press. Firstly, medical registration is compulsory; and secondly, it applies to individuals rather than to organisations.


It’s not a very good comparison, I freely admit, but it’s the best I can do. And while I’m at it, aren’t there similar “statutory underpinnings” to the self regulation of other professions such as lawyers? I don’t know if there is a “regulator” for judges, but then they don’t like being criticised, and any suggestion of criticism is likely to find you being sent down to cool your heels for a night or two.
However, I think that the scaremongering about the end of a “free press” is no more than puffery; we know that self-regulation hasn’t worked, and more of the same, slightly modified, isn’t going to change things. The difficulties are how to get the main players to sign up, and how to get them to follow a code of conduct.

As far as a code of conduct is concerned, periodic inspections might be a way; the encouragement of “whistleblowers”, and some form of sanctions that are actually effective.

But as for compulsory membership; I can immediately see difficulties. The regulation is aimed at major players, daily papers with large circulations; but how do you — should you — separate them from quite innocuous publications such as the Ambridge Gardening Gazette? If some papers opt out, well they come under the aegis of Ofcom according to Lord Leveson, and lose the “carrots”. Whether Ofcom actually wants — or is capable of — this activity isn’t certain. Perhaps the carrots will be a sufficient inducement.

There just might be another approach to this. The editor of the newspaper is, at least in theory, responsible for all the content of the paper. Why not make the editor the subject of the regulation, and let him or her implement the appropriate codes of conduct. No hiding behind any sort of “corporate responsibility”, if there is a problem the editor personally is responsible. Would this be too inhibitory? Would this transfer of responsibility from the organisation to a single, named individual work in practice, or is the work of an editor such that the extra work of ensuring compliance would be excessive. An editor could appoint a “compliance officer”, though this sounds excessively bureaucratic.

No system will prevent all errors; but a sensible system of regulation should prevent malicious defamation of the sort that we are only too familiar with. What we might think of as “honest” errors should be swiftly corrected. (And, whisper it quietly lest they hear, even judges make mistakes; if they didn’t there would be no need for the High Court, the Court of Appeal and the Supreme Court.)

Disclosure: many, many years ago I was once part of a “three wise men” triumvirate.

28 November 2012

5% (part 1 of 3)

Martin Luther couldn’t have foreseen some of the effects of his 95 Theses. Mind you, it was Jean Calvin, in the “Protestant Rome” of Geneva who gets the credit (or perhaps that should be blame) for one of the most far-reaching.

Calvin believed in the value of hard work, as a route to salvation; and also believed that money as capital should work. Previously, “usury”, the lending of money for interest, was a sin; Calvin approved of it. In his time, usury didn’t have the connotation of extortionate or excessive interest.
Be that as it may, the question is “what is a reasonable rate of interest”? Calvin thought that 5% was reasonable, and in the 17th century in England the maximum allowable was 10%. You could extrapolate this to “what is a reasonable rate for my labour”.

Then there wouldn’t have been any income tax, and the idea of inflation wasn’t such a topic as it is today. Now, we expect to have to pay income tax on the interest, and we see the “real value” devalued; it can be hard to keep the value of the capital intact. Quite recently in the UK, unearned income carried an extra penalty of 15% above the top rate of tax, which itself was 83%; you might think that a tax rate of 98% was extortionate. And you wouldn’t be surprised that it made capital gains, which weren’t originally taxed, more popular.

Despite all this, a rate of 5% seems reasonable to me, even though it’s difficult to achieve today. My capital is, at least in theory, available to an entrepreneur or capitalist to use to make or produce “stuff” or to provide “services”, and to pay me interest periodically, often annually. And the capitalist has his/her costs of production, and will want to set aside “reserves” to allow future development, and to tide themselves through setbacks, recessions and trading anomalies. And capitalism is what ultimately, provides the wealth of a country, not the government, though governments may need to intervene to provide a stimulus.

For some, 5% simply isn’t enough; it will double your capital (ignoring taxes etc) in about 14 years, but this is just too slow. These people are in the “get rich quick” group of financiers, and not just “get rich quick” but also “get very, very rich”. And yet there are limits to the “natural growth” of an economy; getting very rich, very quickly can’t be done through conventional investments. One way to do it is through “trading”; originally, this market allowed companies to buy or sell “stuff” in advance of their needs, in an effort to smooth and regulate their cash flow. But “trading” became an end in itself; it was no more than gambling. And lest you think that this is a moral invective against gambling, it isn’t. But, remember, in gambling, nothing is produced, there is a single pot of capital, and “luck” decides who wins and who looses. And in real casinos, the odds are always in favour of the “bank”. So in “casino” trading, if you make a profit, someone else makes a loss — and some of the losses that have come before the courts are staggering.

There’s a name for this sort of activity: greed.

And I haven’t mentioned companies that shuffle their profits around, to minimise their tax exposure; or multi-national companies that trade amongst themselves, at prices to suit themselves; or why Switzerland is a major centre for coffee and copper trading when neither of these commodities enters or leaves the country. Nor have I mentioned those individuals who hide their assets from the tax man, using machinations that may well be illegal; nor the corruption which seems rife in developing countries whose elite’s main aim seems to be to enrich themselves; nor the vast increases in managerial salaries and perks when the workers’ pay remains static or even falls; or even the bonuses for managers when the company is failing.

And there’s more than just greed to all this: inequality. And inequality is far, far more than just a word. For starters, it breeds poverty.

24 November 2012


There’s another issue about the treatment of women in labour in Ireland, something that was largely hidden for decades. It’s in the open now, even if there are those who would be very happy if it simply went away, brushed under the carpet.

Briefly, there was a vogue for symphysiotomy in some hospitals in Ireland for several decades, at a time when the procedure was generally considered obsolete.

What is a symphysiotomy? What is a symphysis?

A symphysis is a type of joint or “articulation” between two bones. It’s not the sort of joint at the knee or knuckles; a symphysis has a layer of fibro-cartilage between the bones, as a “shock absorber”.

Here, we are concerned with the symphysis pubis, the symphysis between the pubic rami of the innominate bones of the pelvis. It’s at the front, directly in front of the bladder, and very near the clitoris and urethra. There is about 2mm of movement, and perhaps 1º of rotation normally. This does increase in pregnancy, under hormonal influence.

What’s a symphysiotomy? It is the division of the symphysis, to allow greater separation of the two pubic rami. It used to be done for “disproportion”, that is where the mother’s pelvis was too small to allow the foetal head to pass through during labour. This problem was often related to poor diet and rickets.

It’s important to note that a symphysiotomy was done during labour, to allow the labour to proceed; it was in no way a prophylactic procedure.

I checked in a gynaecological textbook*: it describes the increase in the diameters of the pelvis which can be expected from the operation, that is, how much bigger the pelvis becomes. It continues,

“The writer does not approve of or recommend the operation, on account of the danger of leaving the patient in a crippled condition after it”. The author, however, describes how to do it, then, “When delivery has been completed…” describes how to attempt to repair the symphysiotomy. He recommends in addition bed rest for four weeks, and then the use of a pelvic binder “for at least a year”. And,

“There are certain risks connected with the operation which greatly detract from its value. The urethra or bladder or both may be torn. There may be lacerations about the clitoris, which may give rise to troublesome haemorrhage. The sacro-iliac joints may be much damaged or even ruptured. The pelvic symphysis may fail to unite, and thus leave the woman unable to walk properly.” [My italics.]

What’s disturbing about the cases in Ireland is that:

  • The procedure was done as a prophylactic, to enable easier future deliveries. Contraception was not available at this time; the mores of the Catholic church prevailed.
  • It was done as an “alternative” to Caesarian section which was felt to be more dangerous, specially for repeated pregnancies; again, there was no contraception, and “grand multipara” were very common in Ireland.
  • The women were not told that the procedure had been done; their permission was not sought.
  • Even when it was done, it was outmoded, outdated. And there was no attempt at "after treatment", to allow the symphysis to heal.
  • And it took some women many decades to discover the truth, to discover why they couldn’t walk properly, why they were in pain.

A report has been commissioned, but not for the first time there is the feeling that the whole truth has not been exposed, and that the government is sitting on its hands.

You can read more of this truly awful story in the Irish Times at:


(and follow the associated links)

* Full declaration: I’m neither eminent nor a gynaecologist, but the author of the textbook was: my grandfather. His textbook was published in 1908. Yes, you read that correctly, the information is more than a century old: it was as correct then as it was during the 20th century.

"It is the law"

There’s a report in today’s Irish Times, giving a time-line of the events around Savita’s management and death.

If this is accurate, it describes a midwife missing a fully dilated cervix uteri.

A termination was refused — “this is the law” — yet it was appreciated that the pregnancy was doomed, and that a delivery was inevitable.

The comment about “the law” is at variance with guidance provided through the Irish Medical Council.

Read it here:


22 November 2012

What is an abortion?

Seems a simple question, doesn’t it? Everyone knows — or thinks they know — what an abortion is. Just ask the man in the street or the man on the Clapham omnibus. Today, though, it would be the person in the street or on the bus.

Well, it’s not quite as simple as you might think. The Offences against the Person Act 1861 doesn’t actually use the word abortion, it refers to “miscarriage”, but does not define what a “miscarriage” might be — and certainly not in terms of weeks of gestation. It also refers to procuring a miscarriage in a woman who isn’t pregnant; either a “catch all” clause, or just possibly a failure of understanding. (And, would you believe it, there was a successful prosecution against a medic for attempting to procure an abortion in a woman who wasn’t pregnant.)

Abortion and miscarriage are exactly synonymous in medical jargon, though miscarriage usually has the nuance or implication of “natural” and abortion is often taken to be “artificial”. It’s difficult to be certain, but it’s generally accepted that many pregnancies end in a “spontaneous miscarriage”, often without the woman realising that she was pregnant.

A dictionary definition of abortion is the premature termination of a pregnancy, but there is no mention of the period of gestation.

When the 1861 Act was formulated, the idea of “induction of labour” was unknown. Many women today have their labour induced, for whatever reason, by “ARM” — artificial rupture of the membranes — and through the use of pharmacological agents. Would the Victorians have considered this as an “abortion”?

The dictionary doesn’t include “destruction of the foetus” in its definition, even if this is what is commonly accepted today. And many would hold that a termination before 24 weeks is an abortion — after 24 weeks, the foetus is usually “viable”. Viable in the sense that it can survive, albeit with significant support.

If in practical terms we can say an abortion is the termination of pregnancy before 24 weeks, and destruction of the foetus; it’s quite possible that the law hasn’t caught up with this.

And we can also say that a full-term neonate is premature; not as paradoxical as it seems. The human baby can do nothing for itself for several years after birth. The offspring of “lower” animals can stand and search out the teat for themselves within a very short time. Human babies are born “prematurely”, it’s said, because of the size of the brain. The adult female pelvis simply won’t allow anything larger to pass; human prematurity is an evoutionary necessity. And the potential for disproportion between the foetal head and the pelvis explains a lot of the problem of labour, and, sadly, worldwide maternal mortality.

Inquiry II

It’s been a slow-motion catastrophe. An inquiry is announced, to be held in secret, with no names being named. Three participants were expected to be both witnesses and judges; they were then to be replaced.

The widower, through his solicitor said he wasn’t going to assist this inquiry; and the solicitor says that some of the medical notes appear to be missing.

The government resists calls for a thorough inquiry, a tribunal.

And then the President makes a thoughtful statement.

And now, the Irish Times reports, the Health Information and Quality Authority has been asked to initiate a statutory inquiry. The original inquiry still seems to be active.

Who would have foreseen this?

Edit 23 November: The HIQU will undertake an inquiry. But, the validity of its inquiry has been questioned, and it may not call witnesses under oath.

Meanwhile, Mr Halappanavar in considering an action at the European Court of Human Rights.

Don't hold your breath, this saga looks set to run and run.

Double negatives

The statue defining abortion throughout the British Isles is the Offences against the Person Act, 1861. It applies in the Republic of Ireland as that state “took over” pre-existing UK legislation when it was founded. The Abortion Act 1967 does not legalise abortion in England, Wales and Scotland; rather is provides a legal defence to a criminal charge. This Act does not apply to N Ireland.

The relevant parts of the 1861 Act are sections 58 and 59:

Every woman, being with child, who, with intent to procure her own miscarriage, shall unlawfully administer to herself any poison or other noxious thing, or shall unlawfully use any instrument or other means whatsoever with the like intent, and whosoever, with intent to procure the miscarriage of any woman, whether she be or be not with child, shall unlawfully administer to her or cause to be taken by her any poison or other noxious thing, or shall unlawfully use any instrument or other means whatsoever with the like intent, shall be guilty of felony, and being convicted thereof shall be liable . . .
Whosoever shall unlawfully supply or procure any poison or other noxious thing, or any instrument or thing whatsoever, knowing that the same is intended to be unlawfully used or employed with intent to procure the miscarriage of any woman, whether she be or be not with child, shall be guilty of a misdemeanor, and being convicted thereof shall be liable . . .

(The penalties available on conviction have changed since 1861.)

Both these sections are a bit hard to follow; I’ve added emphasis here:

Every woman, being with child, who, with intent to procure her own miscarriage, shall unlawfully administer to herself any poison or other noxious thing, or shall unlawfully use any instrument or other means whatsoever with the like intent, and whosoever, with intent to procure the miscarriage of any woman, whether she be or be not with child, shall unlawfully administer to her or cause to be taken by her any poison or other noxious thing, or shall unlawfully use any instrument or other means whatsoever with the like intent, shall be guilty of felony, and being convicted thereof shall be liable . . .

Whosoever shall unlawfully supply or procure any poison or other noxious thing, or any instrument or thing whatsoever, knowing that the same is intended to be unlawfully used or employed with intent to procure the miscarriage of any woman, whether she be or be not with child, shall be guilty of a misdemeanor, and being convicted thereof shall be liable . . .

The word I’m concerned with is “unlawfully”, repeated several times in these sections. To paraphrase the Act, “it shall be unlawful to do an unlawful thing”. There is no mention of “lawful”.

The law was tested in the case of R v. Bourne in 1938. Aleck Bourne was a gynaecologist who performed an abortion on a 14 year old girl who had been raped by several soldiers. The judge apparently said that an abortion could be lawful to prevent the mother becoming a “mental and physical wreck”. The jury acquitted Bourne.

I’ve not found it in my researches, but I was told by someone who was a contemporary that part of the defence was based on “lawful”; that the Act described what was “unlawful”, but implied by omission that there could be circumstances that were “lawful”.

This “double negative” does provide a very minimal tolerance of abortion in N Ireland, where the mother’s health is compromised; but there is no allowance,for example, for the legal abortion of foetuses with abnormalities incompatible with life. (There have been other legal judgements, this is the gist.) Obviously, the Bourne judgement does not apply to Ireland.

20 November 2012

Patent leather shoes

There’s a report in the Irish Times today (20 November 2012) about the responses of the Irish Bishops to the death of Savita Halappanavar.

TheBishops say that the church “has never taught that the life of a child in the womb should be preferred to that of a mother”.

Well, I may be getting on, but I can remember clearly being told that when it came to a choice between the life of a child (or foetus) and the life of the mother, then the life of the child took precedence, the mother’s life should be sacrificed that her child might live. This was the “guidance” as obstetricians understood it.

The Catholic church’s position on abortion has changed over the centuries; earlier, the time of “ensoulment” was taken to be at quickening, so that abortion before this time was not homicide. The church’s present position is apparently based on the teachings of St Thomas Aquinas, who wrote:

the vegetative soul, which comes first, when the embryo lives the life of a plant, is corrupted, and is succeeded by a more perfect soul, which is both nutritive and sensitive, and then the embryo lives an animal life; and when this is corrupted, it is succeeded by the rational soul introduced from without (ie by God).

I really don’t understand how he could have derived this, but I’m not a theologian.

The church does have “form” as far as woman are concerned, particularly feminine sexuality. Sts Jerome and Augustine entertained ideas which today seem very strange — that celibacy was preferable to sex, because, of course, sex was bad and immoral, but if the flesh was weak, well so be it. Another set of ideas that I can’t fathom.

You might well think that the church has “sex on the brain”; you might think that male theologians are sexually repressed; you might well think that the church is keener on “control” than education.

You may have heard the urban myth that well brought up, convent educated, good catholic girls don’t wear patent leather shoes, for fear that boys would see the reflection of their knickers in them. I’ve never looked, but I find this idea improbable.

And I would have dismissed this as anti-catholic propaganda, had I not heard if from a well brought up, convent educated, catholic woman who was taught this. And it wasn’t a joke.

A flawed inquiry?

There is to be an inquiry into the death of Savita Halappanavar. It is to be headed by an external expert, a professor from one of the London teaching hospitals.

Three of the seven members of the panel are employed at the hospital where Savita died, though we are told that they were not involved in her management. They are a consultant in anaesthesia, a consultant in infectious diseases and the professor of obstetrics and gynaecology.

These three are to advise the panel on local procedures and policies. They are to be ‘excused’ from the questioning of those directly involved in Savita’s management.

Now, while it’s sensible for the panel to be informed on local policies, it does mean that these three people will also be evaluating their own policies and the policies and actions of their colleagues; they are to be both ‘witnesses’ and ‘judges’. You might well think that this gives rise to a significant conflict of interests. You could argue that such a duality will allow the inquiry to be much quicker than otherwise would be possible.

This is not to say that the three won’t discharge their duties to the best of their abilities. But it must make it hard for them to be impartial, to be disinterested; they will have to work with their colleagues in the future.

And that surely is the weakness of this inquiry; no matter what the report eventually shows and recommends, it will be hard to escape any charge of bias. And therefore there will be a call for a truly impartial inquiry.

Unsurprisingly, Savita’s widower, Praveen Halappanavar, is calling for a full public inquiry, with witnesses questioned and cross-questioned under oath.

Edit: the Irish Times reports (20 November, afternoon) that local staff have been removed from the inquiry.

19 November 2012

Further thoughts on abortion

Abortion in the UK and the Republic of Ireland ("the state") is illegal; both countries are subject to the same Offences Against the Person Act 1861. In Great Britain — but not in N Ireland — the Abortion Act 1967 did not make abortion in certain cases legal; rather, it provided a legal defence to any charge of procuring an (illegal) abortion. When the Republic was founded, is continued with the common law legal system, and kept pre-existing laws.

In the Republic there have been no legislative changes in relation to abortion. However, the Supreme Court gave a ruling in 1992, permitting an abortion in very limited circumstances, where the life of the mother was in danger. Not just her health, it had to be her life which was endangered. There is no law which confirms this. The Irish Constitution now recognises that life begins at conception; the value of the mother’s and the foetus’s lives are equal.

The 1992 ruling came about in relation to the case of ‘X’, a fourteen-year old child who had been repeatedly raped and had become pregnant. Before taking her to England for an abortion, the father asked of the Garda (police) whether the foetus’s DNA would be useful. X’s planned trip became known to the authorities, who applied to the High Court; and the Court banned X from leaving the state. (You read that correctly; X was banned from leaving Ireland.) An application to the Supreme Court overturned this, permitting X to travel, and, as X was suicidal, issuing its guidelines. You might well think that “hard cases make bad law”.

The present position is that the original act is still in force, very slightly modified by the Supreme Court, but without legislative weight; unsurprisingly, there is confusion about what can be done and what cannot be done. (No accurate data are collated, but it does seem that quite a few “abortions” are performed yearly in the state. I don’t know whether these are the result of applications to the High Court.)

As far as I know, there is no legal definition of what “abortion” is and what is not in Ireland. (A dictionary definition of abortion is the premature termination of a pregnancy, without indicating any time limits. Other definitions might be termination before, say, 24 weeks. After this stage any procedure presumably becomes an “induction of pregnancy”. More than just semantics?)

There are some quite depressing instances where perfectly sensible management cannot legally be offered.

Thus, there are occasional sad cases where the foetus dies in utero, but is not expelled as a ‘spontaneous miscarriage’ or ‘spontaneous abortion’. It is possible for the dead foetus to be retained for several weeks, or even a couple of months, during which the mother’s life is not immediately in danger, though potentially it is. It seems to be illegal to ‘abort’ this dead foetus in Ireland; the mother must travel to England, or the Netherlands, for what would otherwise be seen as the correct and appropriate management. Does a dead foetus have the same rights as a live one?

The foetus may show evidence of abnormalities incompatible with life on routine scanning, for example, anencephaly. In this condition, the brain does not develop. Does such a foetus have the same rights as a healthy one? Again, a mother confronted with such a problem cannot be managed legally in the state; she must travel abroad. Alternatively, exactly what are the benefits from allowing the pregnancy to continue to term?

Lest you think I’m inventing scenarios to make a case, there are occasional anecdotal reports of women with such problems being refused treatment, being told that appropriate management in the state would be illegal.

What of an ectopic pregnancy, one that develops in the Fallopian tube rather than in the uterus? Untreated, the pregnancy will grow, and burst the tube, with considerable bleeding, which if not arrested, can be fatal. A tubal pregnancy can be detected by scanning before it has reached a dangerous size; one method of management is pharmaceutical, causing the foetus to die and be expelled. (Alternatively, early operation may abort the pregnancy but salvage the tube.) The woman is saved the risks of rupture and the risks of emergency surgery. Is this legal?

If a woman becomes pregnant after rape, if her life in in danger — if she is suicidal — abortion is legal, or at least there is a Supreme Court judgement to comfort the surgeon. But if her life is not in danger, yet she wishes an abortion, the procedure cannot be legally performed in the state. She must go abroad. She is the victim of a crime, yet must carry the consequences of that crime; and for how long?

I’ve said nothing about abortion for ‘social’ reasons, about abortion ‘on demand’, and I don’t intend to, other than to indicate that what I’ve discussed above falls into a different category.

But I will comment on two other areas. Firstly, the widespread use of propaganda by both “pro-life” and “pro-choice” groups, rather than accurate facts; the use of “scare tactics”. This doesn’t help either side. Secondly, there is no male equivalent of abortion, no operation or procedure that is in any way comparable. And yet many of those who are most vocal are men. Men in the “pro-life” group seem to think, inter alia, that they still have control of women’s bodies; their thinking seems unchanged from the neolithic origins of the patriarchy, with its insistence on virginity and the rights of inheritance, though they are probably unaware of this, and would deny it. At least, that seems to be how they express some of their arguments.  And “pro-choice” men, who are perhaps a minority amongst men, what is their agenda? Most of the Irish legislature is male.

15 November 2012

Savita's legacy

The death of Savita Halappanavar was first reported on Tuesday, 13 November 2012, and was widely reported the following day in the Irish and UK press, and elsewhere; and the comment continues. Briefly, Savita was 17 weeks pregnant and was admitted to a hospital in Galway, Ireland. She was found to have a “dilated” cervix, from which amniotic fluid was leaking. It’s not entirely clear what treatment she was initially given; subsequently she developed a temperature with evidence of sepsis, and the pregnancy was “terminated” by delivery; soon afterwards she died. During her hospital stay she and her husband requested an “abortion” but were told that this was impossible and “illegal” as “this is a Catholic country”.

There are so many inconsistencies around this story, it’s hard to know where to begin. And,at this stage, the details of her management are incomplete. There are at least two on-going inquiries into her death.

Nonetheless, as fas as I can discover at this stage, she complained of severe back pain, and had a fully dilated cervix,  with evidence of ruptured membranes. This combination of features is an “inevitable abortion”, one in which no matter what treatment may be tried, the pregnancy cannot continue towards a full-term delivery. The management is the delivery of the foetus; this prevents, as far as possible, sepsis and septicaemia; it is an acceptance of the “inevitable”. The presence of a foetal heartbeat is irrelevant; the foetus is doomed — at 17 weeks, a foetus cannot survive outside the womb. Nothing can be gained by delay. Terminating the pregnancy is not an “abortion”, rather is a delivery, the ending of a process which has already begun. Whether “abortion” is illegal, whether Ireland is “a Catholic country” is irrelevant.

I cannot understand why the standard management of an “inevitable abortion” was not followed here. Even if the cervix wasn’t fully dilated initially, the fact that it was “open” means that the miscarriage will become “inevitable”. I don’t understand why the foetal heartbeat had to disappear before she could be delivered; not do I understand why she had to develop signs of septic shock before she was delivered. Despite the presence of a heartbeat, it’s likely that dead tissue and blood clot were present — perfect breeding grounds for infection. And it’s quite possible to have a heartbeat but to be brain dead.

The risks of delay are infection, akin to puerperal sepsis, and DIC — disseminated intravascular coagulation. These combine to produce multi-organ failure, which seems to have been the proximate cause of Savita’s death.

Savita suffered a “mid-trimester” miscarriage or abortion. These are not spontaneous; they do not occur for no reason. For example, there may be chromosomal defects; placental abruption — where the placenta becomes detached from the uterus, or infection, though this is not a comprehensive list. In a way, you could think of a mid-trimester abortion (and a first-trimester abortion) as the body recognising that there is a problem with the foetus, and seeking to manage the problem by expulsion of the foetus. (In a “threatened” abortion, there is vaginal bleeding, but the cervix is closed; such a pregnancy can certainly continue to full-term.)

An “abortion” is the premature termination of a pregnancy; it may be “natural”, or be caused artificially. The word “miscarriage” is usually applied to a “natural” event; but the two words are really exactly synonymous, even if there is a belief that “abortion” is artificial. While it’s difficult to be certain, it’s suggested that about a third of all pregnancies spontaneously abort. In the first trimester, the woman may notice nothing more than a somewhat delayed and heavier than usual “period”.

There are at least four broad indications for an (artificial) abortion:
1. As a method of contraception — this is what is commonly meant by “abortion”.
2. When there is a major foetal abnormality, which is incompatible with life — such as anencephaly.
3. When the foetus has died in utero, but the body has made no effort at expulsion or delivery.
4. Where the mother’s life is endangered if the pregnancy continues. The danger might be mental — suicide, or physical — such as in eclampsia (a complex condition, with very high blood pressure, the risk of stroke or organ failure, etc.)

All and any abortion is illegal in Ireland. When the State was founded, it took over laws passed in the UK parliament beforehand, including the Offences against the Person Act of 1861, which made procuring any artificial abortion illegal.

However, following the case of “X” in 1992, the Irish Supreme Court offered some guidance; that abortion could be permissible if the mother’s life was in danger; not just if her health was endangered, but her life. There is no legislation, however, only guidance from the Irish Medical Council, based on this ruling.

“X” was a 14 year old child who had been repeatedly raped by a neighbour, and became pregnant. Before going to England for an abortion, her parents enquired of the Guarda (police) whether foetal tissue would help to prosecute her rapist. The facts of her case ascended to ministerial level, and mindful of the necessity of conserving the sanctity of the state, an application was made to the High Court, who passed an order preventing X’s removal from the state for the purposes of an abortion. (You read that correctly; X was banned from leaving the State.) This was overturned on appeal to the Supreme Court; and X either had an abortion in England, or suffered a miscarriage, depending on the version of the story you read. Note that the sanctity of the State was held, by the minister, to be above the welfare of the child: X was, unsurprisingly, suicidal.

(Abortion remains illegal in the UK; the Abortion Act of 1967 did not legalise abortion, but provided a form of legal defence to a charge of performing or procuring an illegal abortion — a legal nicety.)
So, even if you think that Savita should have had an “abortion” — rather than having the miscarriage completed by delivery — there are grounds for thinking that there would be a legal defence were there to be a challenge.

And as for the “Catholic country” argument; I’ve always understood that Catholic dogma required any doctor, when faced with the dilemma of whether to save the mother or the foetus, to strive to save the foetus, even if this meant that the mother died*. I’m not sure if this is still the case; but I did read one of the very few clerical responses to Savita’s case, that a “termination” would have been acceptable to the Church. (Savita was not a Catholic.)

There has been a lot of emotional reaction to Savita’s death, and the lack of abortion provision in Ireland. And there have been some comments trying to muddy the waters. For example, I’ve seen comments like: “Ireland is one of the safest countries for pregnant women, we have a very low rate of maternal death. There is no abortion in Ireland”. Both of these statements are correct — though there are countries with better maternal death rates. Irish women seeking an abortion go to England or the Netherlands. But there is no connection between maternal death rates and the availability of abortion — indeed, there are countries with lower maternal death rates which do have legal abortion. And the attempt to conjoin these two statements as a “post hoc, propter hoc” argument is nothing short of disingenuous and immoral; it says more about the lengths that some people will go to to support their point of view, the fragility of their position; their wilful blindness to the reality.

The Irish government has sat on its hands for the last 20 years, almost hoping that the abortion problem would quietly disappear. But they have received a report on the provision of abortion in Ireland within the last week, and are due to respond to the EC in Brussels by the end of the month.
For many people, the Hippocratic Oath from around 400BC prevents a doctor from performing an abortion. There are several versions of the oath, all with similar provisos. However, the intent behind the Oath seems to be either (1) that the physician should leave an abortion to a surgeon, or (2) that the physician should leave certain methods of abortion to a midwife, while retaining the right to perform others himself. In a nutshell: the Oath does not absolutely prohibit an physician from performing an abortion. Many choose to take the provisions of the Oath literally — well some of them; not performing abortions, yet charging fees to brother physicians and their families.

So, to return to Savita, where does all this leave her? The medical management of an inevitable abortion (miscarriage) is well established; there are safeguards, if only a matter of legal interpretation, were she to have had an “abortion”; yet she died.

I suspect that “a Catholic country” must bear much of the responsibility. There is no special place in the State’s constitution for the Catholic church, it is in no way an “established” religion. Yet almost all children in the State will have been educated in a catholic school, and have been subject from an early age to the teachings of the Church. And the Church’s orthodoxy, based on the ideas of St Jerome, St Augustine and St Thomas Aquinas amongst others, are quite remarkably — virulently — anti-women. In brief: the church has a major problem with sex, sexuality and with women. Just do a quick Google search.

Doctors don’t work in isolation in hospitals; there are lots of others who have an input into decisions, none more important than nurses. The english nomenclature of “Sister so-and-so” when referring to a nurse harks back to when all nurses were nuns. And nuns are still an important group of nurses in Ireland today. Further, while many nurses are intelligent and open-minded, many, alas, have a very narrow view of things, their views being based as much on religious teaching as on medical fact. And don’t forget the Magdalene laundries, and what nuns did to girls there.

It’s not easy to present a dispassionate, disinterested view about abortion; it is a very emotional issue. And if you have been brought up in a country saturated with Catholic teaching — even if the church has lost almost all moral authority in the last twenty years, with homosexual and child abuse “scandals” — it’s next to impossible to put this behind you, particularly if you are, despite everything, a person of faith. So your Weltanschauung is intrinsically biased; and it’s very difficult to conceive of other, equally or more valid, views.

And the Irish governments? It’s a very divisive  issue there — and it won’t surprise you that the Dáil (parliament) is predominantly male, nor that the present Taoiseach (Prime Minister) is a “devout” catholic, nor that there are “party positions”.

The physicist Max Planck’s quantum theory was ridiculed when first presented. It gradually gained currency. When asked, twenty years after he had advanced it, why it had come to be accepted, Planck answered, “They all died”. He realised that it’s impossible to change some peoples’ minds, that change has to await the next generation.

Let’s hope that Savita’s legacy is that the next generation is here.

* Edit: I've seen this confirmed in the Sunday Times of 25 November. The reason for preferring the foetus over the mother is that the mother has been baptised, while the foetus hasn't -- and should be given this chance.