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.

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