Dáil Éireann

Select Committee on Health Debate (8 November, 2018)

Health (Regulation of Termination of Pregnancy) Bill 2018

Extracts re: Conscientious objection (P. 26-51)

Copyright the Houses of the Oireachtas. Reproduced under the Oireachtas (Public Sector Information – Open Data) Licence. Links, comparative tables and annotations added by the Protection of Conscience Project.

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Full Text

Committee Members

Deputy Stephen S. Donnelly,

Deputy Margaret Murphy O’Mahony,

Deputy Bernard J. Durkan,

Deputy Kate O’Connell,

Deputy Simon Harris (Minister for Health),

Deputy Jonathan O’Brien,+

Deputy Alan Kelly,

Deputy Louise O’Reilly.

+ In the absence of Deputy Louise O’Reilly for part of meeting.

In attendance:

Deputies Ruth Coppinger, Peter Fitzpatrick, Mattie McGrath, Carol Nolan, Jonathan O’Brien, Bríd Smith and Peadar Tóibín

[P. 26]

Chairman (Deputy Michael Harty)

Section 23 deals with conscientious objection to which there are 16 amendments. The first amendment is No. 147 in the names of Deputies Mattie McGrath, Michael Collins, Michael Healy-Rae, Danny Healy-Rae, Michael Lowery, Peter Fitzpatrick, Carol Nolan, Michael Fitzmaurice, Noel Grealish and Peadar Tóibín. . .

[P. 27]

Deputy Peadar Tóibin

I move amendment No. 147:

147. In page 15, to delete lines 32 to 35 and substitute the following:

“23. (1) Notwithstanding anything in this or any other enactment and notwithstanding any rule of law, or the terms of any oath or contract (whether of employment or otherwise), no healthcare worker or other person shall be under any obligation to carry out, or to make a certification in respect of, or to participate in carrying out or to make arrangements for the carrying out of, a termination of pregnancy in accordance with section 10, 12 or 13 to which that person has a conscientious objection.”.

Bill text	Amendment 147
Conscientious objection 23. (1) Subject to subsections (2) and (3), nothing in this Act shall be construed as obliging any medical practitioner, nurse or midwife to carry out, or to participate in carrying out, a termination of pregnancy in accordance with section 10, 12 or 13 to which he or she has a conscientious objection.	Conscientious objection 23. (1) Notwithstanding anything in this or any other enactment and notwithstanding any rule of law, or the terms of any oath or contract (whether of employment or otherwise), no healthcare worker or other person shall be under any obligation to carry out, or to make a certification in respect of, or to participate in carrying out or to make arrangements for the carrying out of, a termination of pregnancy in accordance with section 10, 12 or 13 to which that person has a conscientious objection
[Comparison provided by the Protection of Conscience Project]

Obviously, the Minister is quite comfortable in that he feels there is conscientious objection or freedom of conscience in the Bill as it stands. He knows there is conflict on that view not only in this Chamber but outside it among the medical professionals. This is not something that has been plucked out of the air. This is a real concern among many doctors, nurses, midwives, pharmacists and medical professionals who work in the hospitals. The centrality here is that this Bill seeks to bring in a law that allows for the ending of a human life. That is a very significant thing for anybody to be involved in. The referendum was dressed up as choice. If we are going to fulfil that promise of choice we would obviously make sure that nobody is forced into a situation where he or she has to facilitate or be involved in the ending of the life of a foetus.

Amendment No. 147 states that "no healthcare worker or other person shall be under any obligation to carry out, or to make a certification in respect of, or to participate in carrying out or to make arrangements for the carrying out of, a termination of pregnancy". That only relates to sections 10, 12 and 13, and it does not deal with the case where there is a significant threat to the health of the life of the mother.

There is a desire here not to consider international examples because every time we have suggested an international example we have been told we are special and we should just stick to the Irish situation. Our next door neighbour, the British, for example, have awful problems with this. They have a stronger freedom of conscience element within their legislation than we do. The freedom of conscience states that there is nothing in this Bill that will force anybody to carry out an abortion but it does not look beyond necessarily the horizon of this Bill and, therefore, there could be other contractual arrangements or other unforeseen consequences that forces an individual to participate.

This amendment also broadens out participation in an abortion rather than the narrow definition with which the Minister has identified. It reframes the section and, again, offers clarity. I was involved in the 2012-2013 abortion discussions and clarity was the goal and lack of clarity was the enemy with regard to that. The British, for example, are laden down with regular litigation involving the state because of certain individuals, healthcare workers, who are constantly battling, trying to protect their freedom of conscience.

The case of the Greater Glasgow Health Board v. Doogan and another is an example of this. New Zealand has come to the view it is important to have a gold standard with regard to freedom of conscience and the amendment emanates from its legislation, which states

Notwithstanding anything in any other enactment, or any rule of law, or the terms of any oath or of any contract (whether of employment or otherwise), no registered medical practitioner, registered nurse, or other person shall be under any obligation

(a) To perform or assist in the performance of an abortion ...

[P. 28]

New Zealand is a progressive western democracy where access is not sought to be denied to anybody yet it has managed to process this with an allowance for other individual human beings to have their own choice respected. I stated yesterday that the limits of my rights end when they start to infringe on the rights of someone else. I mentioned the 650 doctors who have said they will not participate in the process here.

Will I speak to the other amendments in the group now? I am happy to do so.

Chairman

The Deputy can proceed.

Deputy Peadar Tóibin

The other amendments seek to tidy up the elements on freedom of conscience. Amendment No. 148 looks to delete "or midwife" and substitute "midwife, hospital or institution".

Bill text	Amendment 148
Conscientious objection 23. (1) Subject to subsections (2) and (3), nothing in this Act shall be construed as obliging any medical practitioner, nurse or midwife to carry out, or to participate in carrying out, a termination of pregnancy in accordance with section 10, 12 or 13 to which he or she has a conscientious objection.	Conscientious objection 23. (1) Subject to subsections (2) and (3), nothing in this Act shall be construed as obliging any medical practitioner, nurse or midwife midwife, hospital or institution to carry out, or to participate in carrying out, a termination of pregnancy in accordance with section 10, 12 or 13 to which he or she has a conscientious objection.
[Comparison provided by the Protection of Conscience Project]

There is a great argument as to whether institutions have an entitlement to freedom of conscience or conscientious objection. There are many constitutional reasons to state they do because many of them are run by voluntary organisations that under the Constitution have a right to their particular ethos. Some might say Fine Gael has an ethos and the question is whether one can prevent Fine Gael from proceeding with that ethos and can force it onto a certain direction. I would say that should not happen. Even if we forget about what could happen in the future on this, there is a practical element to it. Yesterday, I mentioned three hospitals where the majority of health workers have stated they will not proceed. I will give the Minister more clean information on this today. The general manager of one of these hospitals has told the CEO of the hospital group it will not participate in the process. We have the moral argument I am making and we also have the reality in which we are functioning. To ignore both in the process with regard to institutions would be a folly.

To a certain extent we are all talking about the details of this and how it will work but it will engage with the real-life crisis in every element of the health service. If we are going to create an abortion service we have to make it real-life-proof. Obviously hospitals are opting out from this even before meeting Dr. Peter Boylan so there is a difficulty for the Minister that has to be recognised. This is the desire of amendment No. 148.

Amendment No. 149 proposes to delete a subsection and remove the new obligation in the Bill for a doctor who has an objection to making arrangements. This is one of the most contentious provisions in the Bill for the medical profession.

Bill text	Amendment 149
Conscientious objection 23. (3) A person who has a conscientious objection referred to in subsection (1) shall, as soon as may be, make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the termination of pregnancy concerned.	Conscientious objection 23. (3) A person who has a conscientious objection referred to in subsection (1) shall, as soon as may be, make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the termination of pregnancy concerned.
[Comparison provided by the Protection of Conscience Project]

As I mentioned earlier, the GP system is stuffed at present and is under fierce pressure. Nobody can get an appointment with a GP for love nor money. The GPs in my town are not taking on new patients. If I were to ring a GP now for an appointment, I would be lucky to get it for next Tuesday or Wednesday. This is the reality. What will the Minister do to the 650 doctors? This is a real question. What will happen to the 650 doctors if they refuse this? Will they be stripped of their ability to practice medicine? Will they be brought in some way to a court? If they continue to refuse will they end up incarcerated? What penalties will happen to a doctor who refuses to make arrangements? Making arrangements is an activity. It is not a passive element. Other abortion services elsewhere in the world function without it. I will leave it at that as I know other Deputies want to speak on this.

Deputy Stephen S. Donnelly

We are all agreed the issue of conscientious objection is very sensitive and held very dearly and reasonably by many medics who are opposed to termination of pregnancy. Many genuine doctors, nurses and midwives throughout the country have been in touch with the Minister, me and all of us to state they have serious concerns about aspects of conscientious objection. It is incumbent upon us to treat these concerns with the utmost seriousness.

I have some questions. The conscientious objection section essentially states two things.

[P. 29]

It states, "nothing in this Act shall be construed as obliging any medical practitioner, nurse or midwife to carry out, or to participate in carrying out, a termination of pregnancy in accordance with section 10, 12 or 13". The conscientious objection is waived in emergencies, in line with all medical law. Certainly the doctors, nurses and midwives who have been in touch with me do not have an issue with this part of the section. They understand they are being given an exemption and they do not have to participate in any way. I have not had a concern raised with me about this. The second element is the kernel of where people are looking for clarity. Section 23(3) states "A person who has a conscientious objection referred to in subsection (1) shall, as soon as may be, make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the termination of pregnancy concerned." I have several questions on both parts of the section, if I may.

The first part exempts from participating in or carrying out a termination and we know from the legislation that it applies to medical practitioners, nurses and midwives. Does it include student doctors, student nurses and pharmacists, either here or in other legislation? As for the transfer of care, the question for a clinician reading this will be what does transfer of care mean. There may be some out there but none of the doctors, nurses and midwives to whom I have spoken have said they will opt out of it and that is the end of the conversation. What they are asking me is what transfer of care means. One interpretation, which we discussed yesterday, is the idea that it is to enable the woman to avail of termination of pregnancy. This could be in a normal case, and not in an emergency case or exceptional case, where a woman is in with her GP who will state he or she will not participate and will conscientiously object but will provide information on the 24-7 helpline staffed by trained clinicians, including doctors, nurses and midwives, give her the phone number and explain there is an opt-in protocol in place for other GPs and that if the woman rings the number, she will be given details of a number of GPs. One therefore is enabling the woman to avail of termination of pregnancy services. We could go to the other extreme, which might be interpreted as stating the GP must contact a colleague, transfer the patient files and discuss the case. Certainly the medics to whom I have spoken have said they are okay with the first of these. They are okay with telling the woman they are conscientiously objecting and giving her the telephone number of the 24-7 helpline and explaining all of the supports that are there. Except in cases where it is medically required, they really do not want a situation where they are heavily involved in transferring case notes and finding colleagues.

Will the Minister address those two points, as it might go a long way to dealing with some of the real concerns that exist?

Chairman

Does the Minister wish to come back in now or wait until we have some other contributions?

Deputy Simon Harris (Minister for Health)

It might be useful for me to come in now as Deputy Donnelly has helpfully outlined the key questions. I have a note I would like to go through as it is important to put it on the record to achieve the clarity that Deputy Donnelly has correctly indicated people want. Before getting to that, I will answer his two questions directly. This includes student doctors and nurses, which is the first point.

Deputy Stephen S. Donnelly

Does it include pharmacists?

Deputy Simon Harris (Minister for Health)

I will get to that with the note. There is the matter of transfer of care. Section 17 of the Protection of Life During Pregnancy Act 2013 relates to conscientious objection, indicating that "A person who has a conscientious objection referred to in subsection (1) shall make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the medical procedure concerned." I make

[P. 30]

this point because the phrase "transfer of care of a pregnant woman" already exists in Irish law. We have been discussing this quite a bit and when we make law in the health area, the regulators of those professions take the law, interpret it and legally proof what it means from their perspective as regulators before transferring it into guidance. This has already been done with that Act. Nobody in these Houses has the ability to discipline a doctor or strike off a doctor. Deputy Tóibín asked what would happen to a doctor and a doctor would want to know how the regulator is interpreting the law.

The regulator has already interpreted the law on that phrase on page 35 of the famous book, the Guide to Professional Conduct and Ethics for Registered Medical Practitioners. Section 49.1 of the book deals with conscientious objection, stating "You may refuse to provide or to take part in the provision of lawful treatments or forums of care which conflict with your sincerely held ethical or moral values." Section 49.2 states, "If you have a conscientious objection to a treatment or form of care, you should inform patients, colleagues and your employer as early as possible." Section 49.3 states:

When discussing these issues with patients, you should be sensitive and considerate so as to minimise any distress your decision may cause. You should make sure that patients' care is not interrupted and their access to care is not impeded.

Section 49.4, which is the nub of the matter, states:

If you hold a conscientious objection to treatment, you must:

- inform the patient that they have a right to seek treatment from another doctor

- give the patient enough information to enable them to transfer to another doctor or get the treatment they want.

The next point is key. Section 49.5 states, "If the patient is unable to arrange their own transfer of care, you should make these arrangements on their behalf." The Deputy has correctly stated that nobody has a difficulty with section 49.6, which states, "In an emergency, you must make your patient's care a priority and give necessary treatment." That is the totality of the guidelines and it is helpful in answering the Deputy's questions on scenarios.

If a woman cannot arrange transfer of care, and remembering there are many heads and scenarios in this legislation, a medical practitioner must of course arrange the transfer of care. That is likely to happen in a hospital scenario. It relates to a very sick woman, who is perhaps unconscious and whose life could be at risk or who could potentially suffer serious harm to health. To be honest, the bulk of this conversation is coming from the GP community and I accept the legitimacy and bona fides in raising it. With a GP, a patient would be involved with a medical consultation. We have discussed the phrase "medical consultation" a lot. In such cases, the patient will be able to arrange her own transfer of care and the GP is only required to give her that information. I hope that genuinely helps the debate. I have discussed this with members of the Medical Council when I meet them in stakeholder forums and I will meet them again next week as part of a broader stakeholder gathering on the matter.

The Deputy mentioned pharmacists and a 24-7 helpline, and I glad he did. We discussed this yesterday. Everybody has been approaching conscientious objection from the doctor perspective but as the Deputy rightly says, we must also approach it from the woman's perspective. Nobody wants a woman to have to go around trying to find a doctor either. We have done much work on this outside of the legislation on the 24-7 helpline. The idea is that doctors will have the opportunity to opt in and have their information available to that service. A woman need-

[P. 31]

ing advice or a service would be able to pick up the phone 24-7, speak to a counsellor, nurse or midwife - a healthcare practitioner - and the woman could be directed to an appropriate place. I do not see a problem from a legal perspective for the reasons I outlined but there is also the practical perspective. This legislation should not, in any way, shape or form, be about discommoding women in accessing a legal service. Nor should it be about catching out doctors who have conscientious objections that they are entitled to have.

I genuinely believe the balance is right. What we are introducing in conscientious objection in this legislation is not new or a different construct. It is not more or less onerous than what has existed. It is exactly what has normally been done. I am concerned a little about some of the commentary from some medics raising the issue of conscientious objection because doctors know it is the regulator - the Medical Council - that makes the interpretation and they should be very familiar with what I have just read. I hope that answers the question.

The matter relating to pharmacists has come up a bit. In the primary care setting from an operational and service perspective, the intention is for the doctor to dispense medication to the woman, thus removing the need for the woman to have to make another trip to another healthcare professional, which would be the pharmacist in this case. In the hospital setting, I am sure pharmacists would be involved with dispensing and, in some cases, supplying the medication to the doctor. In that sense there is a role that pharmacists would have. They already have a code of conduct and it states that pharmacists must "ensure that in instances where they are unable to provide prescribed medication or pharmacy services to a patient, they must take reasonable action to ensure these medicine services are provided and that the patient's care is not jeopardised". Information is available on the Pharmaceutical Society of Ireland's website with respect to referendum in May and the next steps, stating:

The statutory code of conduct for pharmacists sets out the principles for professional practice and behaviour which patients, members of the public and other health care professionals and society generally require and expect of pharmacists who are registered with the PSI. The code of conduct is intended to provide support and guidance to pharmacists as they discharge their professional duties. The code requires pharmacists to ensure that in instances where they are unable to provide prescribed medicines or pharmacy services to a patient, they must take reasonable action to ensure those medicines and services and provided and that the patient's care is not jeopardised.

These are similar principles to what we have just discussed with respect to doctors.

Deputy Stephen S. Donnelly

I thank the Minister, as that is really helpful. Many pharmacists will ask if they will be in a position where a woman could comes to the pharmacy seeking an abortion pill that they could conscientiously object to providing it.

Deputy Simon Harris (Minister for Health)

Yes. Their code of conduct already states that they can do it but need to take reasonable action. In other words, they might need to identify where the service may be available. The following may not be well known but it is important for pharmacists from a services perspective; we are discussing the law and this is somewhat separate in that it is the operation of the law. It is not envisaged that woman will be walking into a pharmacy to access medication, as it is envisaged she will get it through her doctor.

Deputy Stephen S. Donnelly

I thank the Minister and that is really helpful. We have discussed general practice but in the acute setting, doctors, nurses and midwives will be able to opt out and conscientiously object. It is not covered in legislation and I imagine it should not be as it is an operational matter. Will the Minister speak to the concerns that some may have about

[P. 32]

concerns relating to rostering, for example? In a smaller hospital, for example, there may be a very limited number of obstetricians or midwives. How are they protected in ensuring they are not rostered into a situation if a colleague is on leave, sick or whatever? Is it possible they may end up being asked to participate in a termination?

Deputy Simon Harris (Minister for Health)

That is an important point. One of the reasons it is so particularly important relates to what we discussed yesterday and even the day before about certification. If an obstetrician certifies a woman for a procedure but goes on leave and the covering obstetrician has a conscientious objection, it demonstrates the importance of rectifying what the Deputy, I and others discussed over recent days. We will do that between now and Report Stage or we will certainly endeavour to work together to do it.

Regardless of a rostering or staffing position in a hospital, the right to conscientious objection should not be infringed. We must work together with the HSE and Dr. Boylan to ensure the service is operable but we must also ensure we do not attach disproportionate concerns to some matters. It is highly likely, based on the trends that we know relating to abortion in Irish women so far, that approximately 80% of Irish women who access terminations will do so in the community setting.

We should park the issue of the nine to 12 week period, which I accept is different from what I am about to say. Other than the nine to 12 week period, the women whose medical well-being the Deputy is discussing are very sick in terms of the risk to their health or life and may well have to be transferred to one of the larger tertiary maternity hospitals. I do not mean this disrespectfully, but I heard some obstetricians in smaller units in the country campaigning for a "No" vote during the referendum campaign and saying, "The eighth amendment has never prevented me from providing care for such a woman." However, that is because such individuals would have transferred their patient to Holles Street hospital, the Rotunda Hospital or the Coombe hospital. Therefore, it does not really arise in the case of a fatal foetal abnormality.

The point the Deputy makes is serious and legitimate. As the HSE rolls out this system, it has a responsibility to work with hospital management to ensure the staff will be consulted, informed and briefed in order that they will be aware of what conscientious objection means. There cannot and will not be any pressure on staff to in any way negate their conscientious objection which they absolutely have a right to have.

I am somewhat concerned about Deputy Tóibín's comments. I do not doubt his words, but I will not cast a slur on any hospital CEO, anonymised or otherwise, because I need to verify the facts. A hospital CEO in any voluntary or HSE institution cannot say, "My hospital is not participating," because it is my clear advice that institutions do not have a conscientious objection. No hospital will have the right to opt out; certainly no hospital CEO will have the right to say, "My hospital is not doing it." I need to ensure we will not exaggerate the significance of this issue. Prior to the introduction of the Protection of Life During Pregnancy Act, we heard many people say, "My hospital will not participate." In fairness to the doctors and medics involved, that largely was not the experience.

I will read my note for the purposes of the records of the committee. I do not want to take too long, but I want to be clear. This is an important issue on and about which we have all had discussions and questions. Section 23 of the Bill covers the issue of conscientious objection. It states that where he or she has a conscientious objection, a medical practitioner, nurse or midwife shall not be obliged to carry out or participate in the carrying out of a termination of pregnancy. In the event that a doctor, a nurse or a midwife has a difficulty in undertaking the required medical procedure, he or she will have a duty to ensure another colleague takes over

[P. 33]

the care of the patient. This is in line with section 49 of the Medical Council Guide to Professional Conduct and Ethics for Registered Medical Practitioners 2016 which I have read in full. That section obliges doctors to enable patients to transfer to another doctor for treatment in cases of conscientious objection. It has clarified how it is interpreted by the Medical Council.

Similarly, the Nursing and Midwifery Board of Ireland Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives, published in 2014, states:

If you have a conscientious objection based on religious or moral beliefs which is relevant to your professional practice, you must tell your employer and, if appropriate, tell the patient as soon as you can. If you cannot meet the patient’s needs because of this objection, you must talk with your employer and, if appropriate, talk to the patient about other care arrangements.

Even if you have a conscientious objection, you must provide care to a patient in an emergency where there is a risk to the patient’s life.

Therefore, both the Medical Council and the Nursing and Midwifery Board of Ireland, NMBI, have mechanisms to address non-compliance with their guide or code by doctors, nurses and midwifes. I am often asked if I am going to sack all of these doctors. Apart from the fact that it is not my function in law, it is not how the Medical Council or the NMBI discharges its duty. These things are only said to shock or create a problem; there is not that sanction.

I have discussed the fact that the HSE is developing a helpline to assist women to navigate the service for a termination. It is intended that medical practitioners will voluntarily consent to have their names released to women who are seeking a termination through this helpline. That will ensure women will be directed to medical practitioners who do not have a conscientious objection to termination of pregnancy.

Both the Bill and the existing medical guidelines make it clear that conscientious objection cannot be invoked when the risk to a pregnant woman's life or health is immediate. Any individual's right to conscientious objection is not absolute and obviously has to be balanced against the competing rights of a patient, particularly the right to life in the case of an emergency. I agree with Deputy Donnelly - I do not believe doctors or nurses have a difficulty in that regard.

I have also outlined what the duty is in non-emergency cases. There are some amendments tabled by Deputies Bríd Smith and Coppinger to this section which we discussed yesterday, perhaps by accident. They are focused on the definition of "as soon as may be" and my decision based on legal advice that it provides for a greater degree of urgency and immediacy than other phrases that laypeople such as those of us around the table might think are more urgent. The phrase "as soon as may be" attaches a significance to informing the patient as quickly as possible.

There is no need to make references to the Protected Disclosures Act 2014, as covered in one of the amendments. The right to conscientious objection is clearly set out in section 23 and does not require a reference to, nor interrupt the interaction of, the Protected Disclosures Act which is already on the Statute Book and will continue to operate independently of this legislation.

Chairman

[P. 35]

Chairman

Will "making such arrangements" refer to what the Medical Council decides?

Deputy Simon Harris (Minister for Health)

That is the case.

Chair

Deputies are offering in the following order: Deputies Fitzpatrick, O'Reilly, Durkan, Paul Murphy, Bríd Smith, O'Connell and Coppinger.

Deputy Peter Fitzpatrick

The Minister appears to think the Bill protects freedom of conscience, but that is not true. Conscientious objection appears to be provided for in the Bill, but on closer inspection, it disappears completely. Freedom of conscience is a vital human right according to the European Court of Human Rights. A person's conscience claims can be religious or non-religious. What matters is that his or her conscience may lead him or her to object or refuse based on his or her deeply held religious, moral, ethical or philosophical beliefs to do or assist in certain things. The best known example is conscientious objection to military service. During the years many people have objected to serving in the armed services or fighting in wars owing to an objection to taking human life.

Many doctors, if not most, are guided by the principle to first do no harm. The idea of intentionally taking human life will be abhorrent for them. Furthermore, the assisting in taking a human life is essentially the same as directly taking it. In the case of abortion the process involves the ending of a human life - there is no ambiguity in this - and after more than 50 years of abortion practices in the UK we see that it clearly involves the intentional destruction of a developing life.

In the Bill the Minister, Deputy Harris, states: "A person who has a conscientious objection [...] shall, as soon as may be, make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the termination of pregnancy concerned." In effect this obliges the doctor to ensure that an abortion is carried out by requiring him or her to make arrangements with another doctor who will perform the abortion. The fact that the conscientious objector is obliged by law to set up an arrangement to enable a woman to obtain an abortion has been overlooked in the discussions on the Government's abortion plan, as discussed with the Chairman earlier.

The Minister for Health, Deputy Harris, has made no intent to engage or consult with general practitioners prior to publishing the legislative plan. Clearly, however, he now wants the new abortion services in Ireland to be GP led. Abortion is not healthcare in any meaningful sense. The intentional destruction of an unborn child is not a therapy, nor is it a recommended treatment for any complication that may arise in pregnancy. Many GPs will be deeply uncomfortable with the ending for no reason of an otherwise healthy pregnancy. Many Irish people will be deeply uncomfortable with the idea that the local GP practice has developed into an abortion clinic on abortion referral services.

Irish doctors should not be forced by law to choose between their job, their business and their reputation on the one hand, and their conscience on the other. These amendments reflect the concerns expressed to us by more than 600 GPs in recent days. We can look at each amendment individually but the key point is that without removing the obligation to make arrangements for abortions we will find ourselves engaged in a massive attack on the rights of our doctors.

Chairman

I thank Deputy Fitzpatrick. Next is Deputy Louise O'Reilly.

Deputy Peter Fitzpatrick

Will the Minister address the issue around the obligation?

Deputy Simon Harris (Minister for Health)

I did talk about that in great detail but I would be happy to revisit it.

Deputy Peter Fitzpatrick

I feel that it is not in the Government's abortion plan. I am aware it was asked earlier on, but I believe the Government has left this out and overlooked it. Perhaps the Minister can tell me-----

Deputy Simon Harris (Minister for Health)

I heard reference to wars here and obviously there is no reference to sending anybody to war. The only thing that is continuing here is a war on women's rights, which needs to end. Earlier I spelled out very clearly how conscientious objection will work. I will state it briefly but clearly again for Deputy Fitzpatrick, and it is the same thing I said to Deputy Donnelly. The provision for conscientious objection exists in section 23 of the Bill. No "medical practitioner, nurse or midwife" need participate in any such procedure based on their own views. They have absolutely every right to hold those conscientious objections and I respect that. The Medical Council guidelines interpret that. The council is the regulator, not me. Section 49 on page 35 of the Medical Council guidelines states this. I have heard from many doctors also, and I accept there are genuine concerns and practical operational questions. I am sure the Chairman will be aware of these from his own colleagues also. I hope that the information I have put on the record of this committee can help to allay those concerns. [The highlighted statement was quoted/cited in subsequent debates. Protection of Conscience Project.]

Chairman

I thank the Minister. I remind members that we are discussing amendments Nos. 147 to 163, inclusive. If a member has amendments within that grouping then please refer to the amendment when speaking. I believe that Deputy O'Reilly has an amendment in that group.

[P. 36]

Deputy Louise O'Reilly

I do indeed. My amendment No. 157 refers to the issue of conscientious objection. I believe that we already have comprehensive provision made for any person who wishes to conscientiously object. I do not hold with the notion that the provision of this specific form of healthcare for women should cause a whole additional layer. Notwithstanding that, we believe it needs to be codified that there would be consequences for those doctors who refuse care to women. Asking a doctor to participate in a procedure is not the same thing as asking that he or she ensures that a provision is made for the procedure to happen.

Bill text

Amendment 157

Conscientious objection
23. (3) A person who has a conscientious objection referred to in subsection (1) shall, as soon as may be, make such arrangements for the transfer of care of the pregnant woman concerned as may be necessary to enable the woman to avail of the termination of pregnancy concerned.

(4) A person who has a conscientious objection referred to in subsection (1)but refuses to make arrangements for the transfer of care of the pregnant woman concerned shall be referred to the Medical Council for appropriate sanction.

[Comparison provided by the Protection of Conscience Project]

Our amendment asks for a referral to the Medical Council for appropriate sanction in the event that a physician refuses to make arrangements for the transfer of care of the woman who is pregnant. There should be a sanction because we do not believe there should be an opt out and that Ireland should continue to do what it has done for decades, which is to look at women in crisis pregnancy situations and fold our hands, throw our eyes up to heaven and say, "No, sorry love we are not helping you." That is not good enough. There has to be an obligation to make a referral for the transfer of care. I do not believe telling a doctor to make a referral is the same as forcing a doctor to participate in any procedure. Any Deputy who comes in to the committee and tries to claim this is being somewhat disingenuous.

The amendment provides for a referral to the Medical Council for appropriate sanction. Although I may have had my own views about whether or not a criminal sanction would be appropriate, the amendment does not say that. It states, "shall be referred to the Medical Council". We are having this debate following on from the referendum, and all of the discussions we had where everybody said there should be no more shame and no more stigma or forcing women to go abroad. It is about putting the woman at the centre and ensuring she gets the care. It is about ensuring that if the doctor or physician in front of whom she is sitting does not wish

[P. 37]

to provide that service then that physician will make a referral onwards. As I said earlier, I do not believe this constitutes participation in any way, shape or form. It simply lives up to the obligations to provide care.

The Deputies have called themselves pro-life - the opposite of which is anti-life, which is silly - and I do not hold with their notion that this part of healthcare should be separate or different. We believe there should be a sanction on any doctor who refuses to make arrangements for the care to be provided if he or she is not willing to do it themselves.

Deputy Bernard J. Durkin

This is a very important element of the legislation and we have to respect the rights of conscientious objectors in all parts of the profession. We must recognise they have concerns that are entitled to be catered for, and we must cater for them. I note the 650 doctors who have signed the petition to the effect that they do not propose to participate. In his reply perhaps the Minister will give some indication of the impact this is likely to have on the overall service available to women in the State.

Other branches of the medical service such as midwives, nurses, trainee doctors - to which the Minister has referred - are also important enough to be provided for in the primary legislation for two good reasons. The first reason is to observe the spirit of the letter of what has been said and promised before. The second reason is to ensure that it is possible to provide alternative readily available services so that women may be able to know where to go without having to make phone calls or do a check. They may have to go in an emergency. They should know before they travel to a particular GP practice if they will or will not receive a service. They should not have to do two or three journeys to find that out. I am aware that the helpline will eliminate some of that. Envisage, however, a situation where a woman might have multiple emergencies - for some reasons outside of her control - and her ability to surmise may be compromised. At this stage it would be better to have a simplified system; a belt and braces system whereby in the first instance the woman would be able to gain access to a medical practice where she knows she will receive the treatment first hand and where she knows she will not put pressure on the conscientious objector or put her own life - or her baby's life - at risk.

I say that on the basis that people may not have made up their minds about what the procedure should be at this stage, and may change their minds. The provision of this service is critically important. I note what the Minister has already said, but it would do no harm to refine it a little to take into account the points I have just raised, with a view to ensuring that the service is available in every region so that the woman does not have to travel 100 miles in order to access basic services. Some medical practitioners in any given practice might have conscientious objections, but others may not. I presume that a situation of co-existence will prevail, whereby those who wish to offer access to abortions can and those who have conscientious objections are not forced into providing it.

Deputy Margaret Murphy O'Mahony

There is a great depth of feeling about this issue. It is probably the part of the Bill that has been spoken about most. With my heart and soul I can fully understand why someone would not want to be part of this. There are many reasons for it. Some people might be pro-life. People should not have to explain themselves. I know that the Minister is aware that the depth of feeling on this issues applies not only to the medical staff but also to the general public. Everyone believes that nobody should be forced to do something that is against what he or she believes in his or her heart and soul. The mental health of medical staff is suffering because of the thoughts of what may be, so it is very important that this is clarified very quickly. Many medical professionals have suggested to me that they would resign if they were forced to do something that they believe to be wrong. We are facing a potential loss of

[P. 38]

good, experienced medical staff. I cannot reiterate enough the trauma that people feel they will go through if they are forced to do something they fundamentally believe is wrong.

One of the main things that helped the "Yes" campaign succeed was the word "choice". I know of many people who were going to vote "No", but when people started to argue for a "my body, my choice" approach their feelings and attitudes to it changed. We must give medical staff the choice if they fundamentally believe that they should not have to do something they do not wish to do.

Deputy Bríd Smith

Unlike Deputy Murphy O'Mahony I am not concerned that there will be mass resignations because of this. I have great faith in the doctors of this country and their ability to deliver this service, and I want to ask the Minister some questions about the doctors who are publicly and vocally objecting. In the Irish medical profession there is a great tradition of being on the side of women, when it has been allowed. In Ballyfermot in the 1960s, 1970s and 1980s there was a notorious doctor called Paddy Leahy, who has now passed away, who was absolutely brilliant at breaking the law and giving women with 12 or 14 children access to contraception when it was totally illegal. Dr. Andrew Rynne also faced down the law on the question of condoms and the contraceptive pill. Doctors for Choice played an amazing role in delivering the result of the recent referendum. In the 1990s, when it was not popular or profitable to promote abortion services, other doctors really stuck their necks out. I am not worried at all that we are going to lose medical practitioners over this.

I agree that the idea of choice was a key factor in the referendum, and that doctors and nurses should have the choice. The issue arises as to what happens if a medical practitioner says that he or she conscientiously objects and what happens next. That is an important issue because transfer of care could mean that doctors will simply provide the phone number for a 24-7 helpline. It should mean that an employee of the HSE or someone who works on behalf of the HSE who meets a woman in a crisis pregnancy asking for the appropriate help has an obligation, because of the contract the HSE has with that employee, to ensure that the woman seeking help gets the care she needs. Ultimately it is the responsibility of the HSE. The way that is provided for in law really matters.

I want to leave open the possibility of putting in a different kind of amendment at the next Stage on the question of the ultimate responsibility lying with the HSE itself rather than the doctor. However, I can foresee hard cases here, and the law as it is written at the moment may not deal with those cases. Transfer of care might be interpreted as merely providing a freephone 24-7 helpline but will do nothing for a young woman from direct provision or from a marginalised community who only knows about a doctor's clinic. She may be impeded by the use of language, her inability to speak English, or a lack of money to make phone calls. There may be many reasons a young woman could not independently look for help outside a doctor's clinic.

We have to be careful not to create hard cases. Having said that, I am pretty confident that most of our medical practitioners would not be that hard-hearted or so cruel to let somebody walk away in a desperate state. There may be some such practitioners out there, and we should allow for the possibility of that. We have to look at how we frame this provision. We have inserted a clause to say that those doctors must refer the woman on to someone who will treat her. We do not quite use that language, but it is clear that the transfer of care is the duty of the doctors. I want to look at inserting an amendment in the future which will make it the ultimate responsibility of the HSE.

As a corollary to the amendment introduced by Deputy Tóibín which seeks to allow an

[P. 39]

institution access to conscientious objection, we have submitted amendment No. 162 which would insist that an institution does not have access to conscientious objection by inserting into subsection (1) that, "Nothing in subsection (1) shall be construed as applying to an institution, hospital or a medical facility".

Bill text	Amendment 162
Conscientious objection 23. (1) Subject to subsections (2) and (3), nothing in this Act shall be construed as obliging any medical practitioner, nurse or midwife to carry out, or to participate in carrying out, a termination of pregnancy in accordance with section 10, 12 or 13 to which he or she has a conscientious objection.	Conscientious objection 23 (5) Nothing in subsection (1) shall be construed as applying to an institution, hospital or a medical facility.
[Comparison provided by the Protection of Conscience Project]

We could leave that out, but we believe it would be better in the legislation as an absolute guarantee that there will be no chance that a place like St. Vincent's Hospital can refuse to provide abortion care because it has a Catholic ethos. Some people are terrified that our future national maternity hospital might have that facility. We want it to be written into abortion legislation that it does not. I believe that is a reasonable request. I take the Minister's point that the legislation includes institutions, hospitals and clinics in good faith.

I have heard that many of the approximately 600 doctors kicking up about this legislation are unhappy because it raises a question about the GP scheme and the payment of GPs in general. Dr. Carthy would know about this. GPs lost a lot during austerity; it has been suggested that there were pay cuts of between 26% and 36%. Those payments have not been restored. I can imagine that a cohort of GPs would be annoyed that they are now being asked to take on extra work without proper remuneration. Can the Minister tell us whether that is correct or not? I do not imagine that there are 600 doctors who are saying that they will not give out the abortion pill. It makes more sense that there would be 600 people who are discontented about pay.

Deputy Simon Harris (Minister for Health)

Deputy Bríd Smith is entirely correct. GPs will obviously have to be remunerated. There is a broader issue concerning general practice into which I am not going to get today, but the Chairman and I are very familiar with it. It relates to the ongoing GP contract talks between my Department and the Irish Medical Organisation, IMO, with the end of the year agreed as the date of completion by both sides. The talks are to address the issues the Deputy has referenced, including the sustainability of general practice, where we want it to be in the future and how we are going to resource it. On the specific issue of resourcing, with GPs to provide the specific new service, I note that in the coming days we will be in a position to issue a contract for the service. It will be very clear for all to see that we are adequately resourcing general practice to provide the service properly, comprehensively and safely. I cannot say any more than that today.

Deputy Kate O'Connell

The conversation on this amendment has included a reference to the belief that abortion is the ending of a human life and that people will be forced to facilitate the ending of a life. We have come back to the use of inflammatory language. Perhaps that is the view, but it is not really the place we are in right now. Previously, people spoke about reasons or offering clarity in reference to these amendments. The Minister has been very clear. The amendment is completely unnecessary and already provided for. As a registered pharmacist, I concur with the Minister's reading of the Bill to the effect that pharmacists have always been allowed to conscientiously object. During the years I personally have had concerns about the idea that anybody in receipt of State payments has had that option, but that is my personal view.

Some years ago I had experience in a town where there was a pharmacist who was a known conscientious objector and did not stock barrier or oral contraceptives and refused to stock Cytotec, that is, misoprostol, for the completion of a miscarriage. My understanding is there was no active referral. However, it was very well known among girls in the town that one did not go to that pharmacy for the contraceptive pill because one would not be given it. Happily, there were nine other pharmacies in the town that could facilitate. There is something like 1,800 retail pharmacies in Ireland and I do not imagine this will pose any problem. However, I do not mean to womansplain anything here, but as the Minister said, one of pharmacist's roles in

[P. 40]

the community is to complete stock orders for GP surgeries. As such, a dispensing process will be involved. In the hospital environment the pharmacy will dispense for prescribing doctors.

I was not going to go there, but there was also a reference to New Zealand. It is really easy to selectively pluck elements of other countries' legislation and bamboozle committee members as if we would not look it up, but I did. Under the Contraception, Sterilisation, and Abortion Act 1977, in New Zealand abortion is available on health grounds up to 20 weeks; therefore, the risks of delay are not as great as under the Bill here. What happens in New Zealand is not at all relevant to the situation here. A doctor in New Zealand can refuse to consider a woman but must inform her of her right to seek healthcare elsewhere. The comparison with New Zealand, therefore, just does not work. It has been statistically proved - it is not merely my opinion - that terminations in New Zealand tend to happen later in the first trimester owing to that longer period.

Let us remember that at the start of the week we spoke about women being at the centre of our discussions. We have to imagine a woman with a crisis pregnancy who is looking for a medical professional's help and how she might feel if she was shown the door. I am of the understanding one can conscientiously object to treatment but not to a person. That is a very important point to consider.

The discussion has proceeded as though conscientious objection is a black and white issue. There is actually a spectrum. Suggesting an institution could be a conscientious objector represents a complete misunderstanding of the degree of objection within the medical profession. Let us consider an institution such as a hospital that is in receipt of State funding. It would be bizarre if it could organise as a collective so as not to provide services for which the people clearly voted.

To my mind, we are yet again seeing a sinister strategy to stigmatise the care required, that is, the procedure of termination of pregnancy; to demean and reduce a woman by suggesting she needs more information; to target the medical professionals who want to be conscientious providers of this service; and to drive willing medical professionals to simply give up.

As somebody who has worked in late night pharmacies at weekends and on Christmas Day for several years, I would like to make a point that the Minister has perhaps considered. There is a need for a book of guidelines for community pharmacists to cover situations where a patient, whom one knows, presents on Christmas day or at 8 p.m. If we cannot get hold of a GP, pharmacists should know the cascade of options to which we refer if we are caught in a situation with a vulnerable woman. Obviously, referring her to a maternity hospital seems to be the logical choice, but that is fine for me as a person in Dublin. A booklet would be helpful for those pharmacists who want to hold it. I am not saying they should be forced to hold them, but there should be some guidelines for community pharmacists in order that we will not be gazing at women in a crisis not knowing what to do with them.

Deputy Ruth Coppinger

I hear a lot from a lot of Deputies today, as well as in a lot of the motions, about freedom of conscience and how absolutely vital and important it is, but for umpteen years I have not heard from any of them about the absolute right to freedom of conscience where people like me are concerned. I did not hear about freedom of conscience for people like me when the Dáil prayer was forced on us and we were forced to stand for it, or with reference to the statue of the Virgin Mary one sees in hospitals. We do not have full freedom of conscience.

[P. 41]

I am becoming a little concerned as the debate goes on. Yesterday I said I was not going to come in, but I am becoming quite worried. It is being suggested doctors, nurses and, as some would love to have it, everybody else will be able to object to providing abortions. All they will be required to do is tell somebody about a website or a 24-hour helpline. That is not what I understood by "transfer of care". The Minister needs to be a little more specific. He was very specific when he wanted to include periods and dates in the law, but he is not being as specific in this instance. I accept the point he made yesterday that "as soon as may be" means a little earlier than we all thought. However, a specific time should be outlined. It should be 24 hours, as proposed in one of the motions. The wording "as soon as may be" is a little too vague. Notwithstanding all of the great doctors in the country, there are some who will actively frustrate women and pregnant people in seeking to have an abortion in this country. They certainly will. Some nurses and midwives will too. They just do not agree or accept that it is a freedom of conscience issue for the woman having an abortion. They accept freedom of conscience only in their case. I have visions of women being passed from Billy to Jack.

If one goes to a doctor and is told there is a website and that is the doctor's duty done, that is not enough. We need to be a little more specific.

Deputy Simon Harris (Minister for Health)

I took "transfer of care" to mean that one must tell the woman that another doctor in her locality - there is no point in referring a woman from Dublin up to Donegal or vice versa - will provide the termination and has the potential to cater for the woman the following day. I thought we would be talking about some kind of referral. The uninitiated among us would read "transfer of care" in that way, so the Minister must explain this. I wrestled with this issue and whether I would oppose conscientious objection completely. There is a case to be made as to whether it should be allowed at all because the way in which it operates in some countries is such that it prevents many people from accessing terminations. We cited examples in Italy, where a culture has been created in the medical community of doctors not participating. One can see how, with political and social cultural shift in a different direction, this could start to happen here.

How onerous is it for a doctor to write a prescription? One could surely argue that it is still up to the woman and that the doctor is not actually participating in the abortion. He or she is giving that choice, that freedom of conscience, to the woman in the situation. I ask the committee to look at it that way. One would think doctors were actively being forced to carry out abortions, which none of us agree should be the case. One is still giving the person affected by the decision that freedom of conscience but one is not carrying out the procedure oneself. All I am hearing about is doctors and nurses. I agree with Deputy Bríd Smith that the majority of doctors will participate in this. Surveys given to the Committee on the Eighth Amendment of the Constitution showed that the majority of doctors, like the rest of the population, were in favour of such provision. I will also be balanced, however. Doctors did not do enough in this country in recent years to actively move the situation forward. Even Professor Arulkumaran said after the inquiry into Savita's death that he was surprised doctors did not do a little more in the intervening years. Be that as it may, doctors are now actively taking part.

I wish to mention some specifics. Some of the amendments basically imply that this should be broadened to all healthcare workers. I myself worked in the healthcare system. If it is broadened, are the Deputies who have tabled these amendments saying a clerical officer could refuse to write a letter of referral for someone or refuse to physically hand a woman a list of doctors in her area? This seems to be what is advocated in these amendments. Not alone that, but what if

[P. 42]

[a receptionist in the surgery has a conscientious objection? There is all sorts of potential here for the matter to be broadened.

The institutions are another matter. I agree that amendment No. 162 should be adopted. We probably should explicitly write this into law and it would be good to do so because there is a serious question mark over it. No one knows what will happen with the national maternity hospital. I would like the Minister to make it clear that he will not accept institutions conscientiously objecting.

Another matter that has come up recently and on which I would like the Minister to give a commitment is the question of an opt-in system. I have been contacted by doctors who are abortion providers in other countries. They have asked me to ensure that such a system is not introduced here because having a list of abortion providers could potentially put certain doctors at risk of attack. We should not be naive. There are people who actively oppose this law and we know they pick on clinics. We know that where they have done so in other countries, doctors and healthcare providers have been attacked and killed. We know they are guilting and shaming women going into abortion clinics in Liverpool today. If we are to have an opt-out system, it must have a limit such that the doctor must ensure that the woman is looked after. Furthermore, we should not have an opt-in system or a list of doctors. I am also worried about this 24-hour helpline, and I mean this for the protection of doctors and staff who work in surgeries too. We do not have an opt-in system for the provision of diabetes services or other healthcare. We should not stigmatise abortion if we can in any way avoid doing so and we should ensure that doctors are protected.

I think there will be enough doctors to provide this service. I will put this in context because I think it was Deputy Fitzpatrick who raised the question of how the healthcare service will cope. We do not know the exact figures, but let us say there will potentially be 5,000 or 6,000 abortions per year, adding up the people who travel and those who order the abortion pill online. We do not know the exact figure for the latter but we have some idea from the two main providers. The current number of doctors will be able to cope, particularly because much of the service, probably up to 80%, would be medical abortion, which simply requires a prescription. I am all for protecting doctors' and other people's rights, but at the same time we must ensure that women, particularly those in rural areas or areas where there are not many doctors, are not left behind.

I wish to raise one last scenario. We had a case two years ago in which a psychiatrist sectioned a teenager who was suicidal and was seeking an abortion. We never heard what happened but this came out in an article in The Irish Times a year later. Doctors who oppose this legislation have a lot of power to frustrate it, so it is important we write into it the limitations of conscientious objection.

Chairman

Our next three contributors are Deputies Tóibín, Nolan and Mattie McGrath.

Deputy Peadar Tóibin

It is interesting how best practice internationally is being solidly ignored in this scenario. I cannot understand why. I gave the examples of New Zealand and Britain. In both countries doctors do not have to make arrangements but abortions happen. Access is not reduced, the law on conscientious objection does not prevent it, etc. We can get lost in ourselves on this issue when, in fact, there are systems functioning, not that I agree with them, in a way that people from the other side of the debate would want them to function without forcing other people to get involved in them. The conscientious objection of a doctor and a cleaner are equal.

Deputy Coppinger had a clean opportunity without any interaction at all from other members. Workers at all levels are equal and should be treated equally. We should not be saying certain workers should be allowed conscientious objection and other workers should not. That is a really important point.

We have been having this back and forth on guidelines and primary legislation for the past three days. This is one area the Minister needs to relinquish. The opposition is not just from what people would call the pro-life side of the debate. There is fair opposition around the country, left, right and centre, on this issue. Primary legislation trumps medical guidelines. Furthermore, this is a change to the medical guidelines. The Minister mentioned the medical guidelines in respect of the Protection of Life During Pregnancy Act. That was a requirement in respect of abortion in cases in which the life of the woman was under threat and had to be protected. For a start, the level of conscientious objection that would exist in such a case is zero. Second, the position would be that the guideline would be deleted if that Act were repealed.

The Chair was very close to nailing it in this situation.

We are introducing a new law and the language in this particular section is the same language as the particular other law, but it is for a different right, not the right to have an abortion in the case where the mother's life is under threat but the right to have an elective abortion in a scenario before 12 weeks for other reasons, and important reasons they may be. It is a different right. Therefore the guidelines designed by the Medical Council on this particular issue will not have to give the same level of precedence to passing information, etc. In actual fact, I have spoken to a number of barristers on this issue and their view is that the Medical Council could not but develop guidelines that actually reflect the law. They would have to respect the law.

When we are discussing a matter and something is thrown out into the ether, I would ask that we be factual.

Deputy Peadar Tóibin

Let us agree with Deputy Smith there, please.

Chairman

I am obliged to offer the members a break because we have been here for the best part of three hours. I will be led by the members.

. . .I am obliged to offer the members a break and I am doing so. I get the impression that we should continue.

Deputy Peter Fitzpatrick

There are two more speakers and then we will go for a break.

Chairman

The next two speakers are Deputies Nolan and Mattie McGrath.

Deputy Carol Nolan

I want to point out that conscientious objection is a major issue. I can see why. I have met a number of GPs and they have genuine concerns. They do not want to have any hand, act or part in the abortion process. It is as simple as that. The legislation as it stands, which my colleague Deputy Tóibín pointed out, does not provide for full conscien-

[P. 45]

tious objection. It was not voted on in the referendum, if we are to be honest about that. That 640 GPs have signed a petition suggests that this is becoming a major problem that needs to be dealt with.

It is appalling that the Minister did not consult with these GPs or sit down with them. The doctors' group released a statement, which he may be aware of, stating quite clearly that they felt bullied and disrespected; those are their words not mine. They have been treated in an appalling manner. Everybody has the right to conscientious objection. Let us be straight that it is a human right. These GPs want no hand act or part in this. Their views should be respected. The legislation is a weak form of conscientious objection. It is not given full conscientious objection or respecting their rights.

The GPs have also pointed out that as well as the Government the Irish College of General Practitioners, ICGP, has also acted in an unfair manner in that it refused to call the EGM until after these amendments are dealt with. What that effectively means is that the legislators cannot hear the voices of the GPs directly. We have met them and I know many of the pro-life TDs have had the courtesy to meet them in our clinics and we have been hearing their concerns. We agree that there is a huge issue here.

If these GPs refuse to participate in this process, and I am totally sympathetic to them, what is going to happen? Are their licences going to be taken? Are they going to be locked up? Are we going to have a flood of court cases because that seems to be where we are headed here? All this is at the end of the day is upholding a fundamental right to conscientious objection. If we do not accept this very reasonable amendment here, we are headed to a flood of court cases. Listen to the GPs and respect them. We are talking here about different choices and views. We all have our own views and nobody, whether they be a politician or a GP or a health care worker, should be forced into taking part in a process with which they fundamentally disagree.

Deputy Mattie McGrath

We are about to have a vote on one of the most important questions we could ever be asked, as to whether this legislation, as put forward by the Minister for Health, would change everyday medical practice. It is no overstatement to say that the Minister has proposed nothing short of a radical change in the model of medical practice and care provided by maternity services in Ireland. We have been contacted by numerous doctors, as has been said, in everyday practice who are shocked that the draft legislation has been proposed without so much as the slightest consultation with front-line care providers whose patients are pregnant women and their unborn babies.

No guidance has been given on the professional liability for the practitioners that may arise in providing abortions under the legislation. No experts have been consulted on the pathetic conscientious objection clauses that are contained in this Bill which in practice would not protect anything .

Despite what the Minister said during the referendum campaign that the law would protect the right to conscience, the so-called conscientious objection clause in the legislation gives no real protections in law for those who do not wish to provide abortions. It is as simple as that. Doctors were shocked to discover that even in circumstances where they object to performing an abortion or prescribing abortion medication, they must make such arrangements to ensure that women requesting a termination are able to do so, which I am quoting from the legislation. The meaning of this is obvious. Where a doctor objects to an abortion, he or she must still ensure that one is obtained. The Government's proposed abortion law goes far beyond the law even in Britain where there is no requirement to make arrangements for abortion access.

[P. 46]

This is a joke.

Deputy Carol Nolan

This is ridiculous.

[P. 47]

Chairman

-----I want respect from the Chair as well, which I am not getting. It is a two-way process. If the Minister starts stripping away licences from GPs or locking them up, as he is threatening if they object, he will go down in history as the most incompetent Minister for Health in this country. Our amendments will ensure that the right to freedom of conscience is protected. They will avoid pointless and expensive court cases but the expense does not matter. They will protect GPs in their work. I am appealing to the Minister but he has set his face against accepting any of them.

I will. If I can speak and the Deputies do not heckle me-----

Deputy Peter Fitzpatrick

We promise that the Minister will be able to speak.

Deputy Simon Harris (Minister for Health)

So far, in the four hours I have been here today-----

[P. 50]

Deputy Peter Fitzpatrick

So have we-----

Deputy Simon Harris (Minister for Health)

No, not all of the Deputies have been here for four hours. Following on from the eleven and a half hours yesterday and the nine hours previously, so far today I have been referred to as simple and as the most incompetent person in the history of the State. There is no decorum here.

Deputy Mattie McGrath

Minister, you cannot-----

[Interruptions]

Deputy Ruth Coppinger

Let the Minister speak.

Deputy Simon Harris (Minister for Health)

Deputy Mattie McGrath

He did not respect us-----

Deputy Simon Harris (Minister for Health)

I have answered them already. I will answer them again and again. This is a delaying tactic-----

(Interruptions)

Chairman

Allow the Minister to speak so that we can proceed to the vote.

Deputy Simon Harris (Minister for Health)

Conscientious objection ----

Deputy Ruth Coppinger

Is the Minister summing up on all of our questions?

Deputy Simon Harris (Minister for Health)

Yes, for the final time. As Deputy Coppinger knows because she has been here, I have answered all of the questions already.

[P. 51]

Deputy Simon Harris (Minister for Health)

Conscientious objection is allowed for in section 23. The issues that the Deputies are suggesting have been voted against already. Of course, we have not voted against them but against the amendments as proposed because we are satisfied that the protections and clarity are already in the legislation. This is no different to the conscientious objection that already exists. I have explained in great detail and read fully into the record of this committee the Medical Council guidelines, referencing specifically section 46 of those guidelines that outlines how conscientious objection works. Deputy Mattie McGrath is not going to like my answer, no matter how many times I say it. I am not going to like his position, no matter how many times he reiterates it.

Given the lengthy discussion I suggest that we vote. I have answered all of the questions.

Amendment [147] put.

Tá [Yea] 0; Níl [Nay] 5; Staon [Abstain] 1. Amendment declared lost

Amendment [148] put.

Tá [Yea] 0; Níl [Nay] 5; Staon [Abstain] 1. Amendment declared lost

[P. 52]

Amendment [149] put.

Tá [Yea] 0; Níl [Nay] 5; Staon [Abstain] 1. Amendment declared lost

Project Note: A number of amendments concerning freedom of conscience that had been proposed (150-153, 157-162) were formally moved and withdrawn. Three (154-156) were not moved.