David Cullinane: Remove Three-Day Wait, Defend Safeguards

Comhairleach, I welcome the opportunity, Minister, to debate the shortcomings in abortion services in Ireland this morning. My priority is access for women to the services which were voted for and endorsed by the people in 2018 and the too many barriers which remain. One of those barriers is the three-day wait. Sinn Féin supports removing the three-day wait. We never supported the three-day wait in the first place. We have tabled legislation to remove the three-day wait and we have always been clear that this waiting period does not provide care. It does not provide support. It does not make the service safer. It simply makes access harder. We do, however, have significant concerns about the proposed new definition for a condition likely to lead to the death of the foetus, which is not grounded in the recommendations of the review of the Act and ignores the intention of a clear and enticed definition. We are also concerned by proposals to decriminalise medical practitioners who knowingly and willfully act illegally beyond the scope of the Act. We have a long history in this country of scandals in women's healthcare. The law is a law, Minister, and medical practitioners should not be given a carte blanche to act outside of the law. I want to address each of these points and the other provisions in the Bill in turn. The provision of termination of pregnancy services was endorsed by the Irish people by referendum, with a clear picture of what those services would look like. The Act was put in place with a clear understanding that the legislation underpinning these services would continue to be reviewed for operational effectiveness. The review of the operation of the Act was published three years ago. The review highlighted serious imbalances in access to care, significant geographic variation in access to services, the underdevelopment of regional services and barriers such as the three-day wait. My priority is that the services which were voted for and endorsed by the people in 2018 are fully operational and accessible to all women. Women should be able to access the services which were voted for democratically, yet there are still barriers for access for many as identified in the review. There is a postcode lottery in access to care. One of the biggest barriers identified in the review was the lack of GPs providing access to early medical terminations and the fact that regional centres and multidisciplinary teams are not fully operational. This creates a postcode lottery in access to care. Only 10-15% of GPs provide early medical termination services which is less than 10 in some counties as of early last year. The review had recommended a geospatial analysis of services to identify the biggest gaps. I am not aware of the Department ever conducting or publishing such a review. Maybe it exists and the Minister might come back on that later. The review provided 75 recommendations to be worked through. Most of the recommendations do not require legislative change. It is important that the House receives an update on the steps the Minister is taking to improve services and access to services through community providers and ensure that hospital-based services are accessible in a timely manner. The Oireachtas did not intend for the Government to do a review and leave it on a shelf. The Minister for Health and the Taoiseach need to step up and implement findings of the review. The Minister should bring forward a progress report on the consideration and implementation of the recommendations of the review. Moving to the Bill before us, I note that the Bill proposes to remove the three-day wait, instead obliging doctors to inform a woman to arrive to a reflection period, to be exercised at the woman's discretion. I support that. To replace the debt within 28 days' prognosis-based definition for a condition likely to lead to death of the foetus, otherwise known as fatal foetal abnormality, with an open-to-interpretation, circular and untested definition to quote that there is presently a fatal condition affecting the foetus, which is not grounded in the OCA report and the review of the Regulation of Termination Pregnancy Act. To remove clinical provisions for medical practitioners who knowingly and willfully provide abortions or access to terminations or advice on terminations which are outside the scope of the Act, which is and would remain illegal in this state. To require practitioners or health professionals who are conscientious objectors to ensure access to abortions in an emergency, though this is already provided for in the Act where there is an emergency threat to the life of the mother. So this amendment at best seeks to be redundant. To remove the requirement for two medical opinions for access to a termination on risk to life for health grounds, allowing access following consultation with a single practitioner. And to require the Minister within six months to quote issue guidelines to provide clarity to medical professionals in carrying out procedures unquote under risk to life held in an emergency and condition likely to lead to the death of the foetus grounds. And finally to require a further operational review of the Act within three years. Minister, as I've said, Sinn Fein supports removing the three-day wait for access to abortion services. We support replacing it with a right to a reflection period. We never supported the three-day wait. This waiting period does not provide care. It simply makes access harder, especially for women in difficult circumstances, whether they are victims of coercive control or domestic violence, rape or sexual assault, or simply found out about their pregnancy too late and face timing out of access to care due to the mandatory wait. It particularly puts women who are subject to controlling or abusive partners or who are from marginalised backgrounds in a difficult position because that first appointment may be the only appointment that they get. The clear feedback from women and the review of the Act was that some women were also being pushed beyond the 12-week threshold by the three-day wait, which defined or denied them their choice to end the pregnancy. We have always said that on personal decisions such as abortion, we need to trust and support women while they are making these decisions. We have all recognised in law and in policy that women should have access to abortion services in the first trimester on the basis of their own free choice. This is the compassionate position put before the people in 2018 and it is the basis on which services have been provided since. Sinn Féin has tabled a targeted bill to remove the mandatory three-day wait. We think that this bill strikes the right balance. It is the right change to make. It respects women's decisions. It removes an unnecessary barrier to care. Minister, removing the mandatory three-day wait does not remove a woman's ability to take more time if she wants to. That option will always remain open to her and rightly so. What our bill does is remove the requirement that the state must force every woman to wait, regardless of her circumstances, her decision, her health or her needs. This is something that can be done quickly and it should be done during the course of this Dáil term. We agree fully with the need for robust, clinically sound statutory guidelines to protect and direct clinicians in providing lawfully permissible services. The absence of guidelines was identified as a serious barrier to many clinicians providing care. Guidelines are essential for addressing the issues identified with the operation of terminations under sections 9 and 10 relating to a risk to the life of the mother and section 11 of the Act for conditions likely to lead to the death of the foetus. Terms such as risk, serious harm and the lack of reliable pathways were identified as problematic due to the lack of legal definition, which asks clinicians to make philosophical judgements and puts them at risk of acting beyond the Act and illegally. This bill makes the same mistake with its definition for a fatal condition. We do not support the proposed definition for a condition likely to lead to the death of a foetus, otherwise known as fatal foetal abnormality. This amendment is not grounded in the statutory review of the Act, which recommended a review with stakeholders to consider alternative grounds that would be clear to apply in practice and would be in keeping with the spirit of the legislation. The proposed definition in this bill is untested and circular. The term fatal is not defined. There are no limits on it. It leaves the philosophical question of life and the balance of probabilities over entirely to clinicians, which is not right and is an abdication of our duty in this House. Most problematically is that this amendment ignores the intention of a clear and tight definition and the process recommended by the review is actually ignored. We should not be inserting untested and loosely drafted definitions into the regulation of the Termination of Pregnancy Act without having followed the right process. Doing what the review recommended, which is to convene stakeholders, including medical practitioners and other relevant healthcare professionals, patient representatives, lawyers and of course women, to obtain a better understanding of the challenges in Section 11 and ensuring that the multi-team fatal medicine teams are properly resourced with the appropriate skills mix. In the context of late-term abortions for fatal anomalies, we are talking about pregnancies which a person wants to keep and made the choice to keep during the 12-week period. For these pregnancies, we need to be working with clinicians and guidelines to give effect to the intentions of the current definition. To consider only minor amendments to that definition to improve its operation and not its scope. And to work together to improve health services for children to ensure that where a family elects to continue a pregnancy that they are supported if their child is born with a condition. There are many conditions which can be recognised under this proposed definition as fatal. Not because they have to be, but because the services to save the child's life are not present or functioning. They are fatal because successive governments have failed to put in place the health services that those children need to survive. There are many conditions which are present at a higher level in Ireland than in other jurisdictions because instead of providing families with the supports and services they need for their child to survive and thrive, they have the option of an abortion because the child has an anomaly. I do not support that. I want to support families who have chosen to keep the pregnancy to have the best chance for their child. I want to support those children to live a good and healthy life. We do not support any slip into the territory of abortion on possibly fatal grounds. We do not believe that disability is grounds for an abortion or that this is in any way a progressive position. I agree that no woman should be forced to carry an unviable pregnancy. I agree that no woman should be forced to travel for services which should be lawfully available on this island. But it would be wrong to insert, in my opinion, such an open-ended, untested and loosely drafted definition which puts families and children in a position where abortion is an option not because the child will not survive, but because the child might die because the state has not invested in the care which the child needs. We are concerned by proposals to remove offences for medical practitioners who knowingly and willfully act illegally beyond the scope of the Act. Abortion services in Ireland are decriminalised for an early pregnancy and otherwise for risk to life or health of the mother or in the case of a condition which is likely to be fatal. We have a long history in this country of scandals in women's healthcare and the treatment of women and children by some parts of the health service. The criminal provisions retained in the 2018 Act are there to ensure that medical practitioners do not knowingly and willfully act illegally outside or beyond the scope of the Act. The law is the law and the medical practitioners should not be given a carte blanche to act outside of the law. I think that would be ludicrous. Criminal sanctions were included in the Act to ensure that only those services endorsed by the people and by the Oireachtas are made available in this state. The way to address issues around criminalisation is through the application of clear, robust statutory guidelines on the provision of services under each different ground. That is how we balance protections for clinicians, for parents and for children. We acknowledge people's right to conscientious objection and the importance of protecting that while ensuring that in emergency cases the life and health of the mother must take priority. I am not convinced on the need for the proposed amendment on this issue. The point is already addressed in the existing law. The issue here again is a lack of statutory guidelines. We need to be very clear on this issue. When there is a risk to the life or health of the woman, there is an obligation on medical practitioners to try to save her life. We need to avoid any repeat of the tragedies that happened under the old system, like what happened to Zavita Halepanavar. Her story is part of why we have the legislation we have today. In a repeat of those circumstances, there should be no barriers or objections to saving that woman's life. In conclusion, it astounds me that we would be looking at this Bill which clearly goes far beyond the recommendations of the review, which disrupts the consensus-based approach which brought about repeal, and which presumes to rip up many of the safeguards which were presented to the people in order to convince them to repeal the Eighth Amendment in the first place. A genuinely constructive approach to improving services for women would have involved engagement across the Opposition to support the targeted Bills which are on the Order Paper for removing the three-day wait, tabled by myself, by Deputy Coppinger and by others who have been trying to be constructive in removing the three-day wait. This Bill has no democratic legitimacy. It is not productive, in my opinion, it is not designed to become law. It proposes to significantly undermine the legal framework which is put before the people. Tremendous work was done by the Committee on the Eighth Amendment and then the Health Committee on the 32nd Dáil to bring this legislation together and to deliver services for the women of Ireland, which also addressed the concerns of people around safeguards and protections for, in particular, children with disabilities. We have approached this constructively. We will work constructively across this House to work through the recommendations of the review, which I think needs to happen, to ensure the services which we voted for are fully operational and accessible, to ensure that women who choose to avail of an early pregnancy abortion have access to GP-led services, to ensure that where there is a risk to life that the mother is prioritised, and to ensure that where there is a fatal condition affecting the foetus that women are not forced to carry unviable pregnancies, but that where a child can live and a family has elected to keep the pregnancy during a 12-week period, that that child is given every chance to survive and indeed thrive.