by Frank Schnittger
Tue Nov 20th, 2012 at 05:49:09 PM EST
The death of Savita Halappanavar has provoked world-wide condemnation of the Irish health service and the social and legal infrastructure which underpins it. There have been allegations of Roman Catholic dogma determining the medical treatments available to non-Catholics in Irish hospitals; allegations of racism; and allegations of a patriarchal medical system and culture that would rather have a woman suffer in acute pain rather than give her appropriate treatment and relief.
Some or all of these allegations may turn out to be true. Some have certainly been true in many other instances in the past, as the outpouring of personal reminiscences by Irish women which have appeared in print and in the media over the past few days testify. The mass protests at her death seen in Ireland and abroad indicate that a very raw nerve has been touched.
But there is also an altogether more innocent explanation of what happened in this particular instance of which we should be aware before we jump to conclusions and condemn all involved. I have spoken to medical personnel with some knowledge of the hospital and staff in question (but with no direct knowledge of this particular case) who rule out the likelihood of racism and point to the possibility of a very different scenario:
Firstly, despite many health service cutbacks, Ireland still has one of the best maternity services in the world with very low mortality rates for both mothers and their babies. When Savita Halappanavar apparently presented at Galway University Hospital with acute back pain, a ruptured membrane, and a dilated cervix, she had the classic symptoms of an impending miscarriage. At 17 weeks the foetus would not have been viable. She was, apparently, advised and accepted that this was the unavoidable outcome.
Standard medical practice under those circumstances would have been to allow the miscarriage to proceed naturally as any surgical intervention (such as an abortion) has its own risks of mishap or infection. The question which arises here however is why her complaints of acute pain weren't, apparently, adequately medicated. It might also have been possible to accelerate the process by inducing an earlier delivery.
Why was this not done? The suspicion has to be either that her condition was not adjudged to have been critical in any way, or that there were "theological" or legal concerns that the "substantial risk to the life of the mother" standard for allowing the induction of a live but unviable foetus had not been met. We do not yet know which was the case, although her husband's statement that they were told that "this is a Catholic Country" indicates that it was probably the latter.
She developed septicemia and subsequently died of an e.coli infection. It is important to note that an earlier miscarriage, induced birth or abortion would not necessarily have reduced her risk of becoming infected. The bacterium is apparently unfortunately very commonly found in Irish hospitals, and she may even have been better off and safer at home - always provided that her pain and general condition was being carefully monitored and managed. Certainly, the foetus itself is unlikely to have been the source of infection for as long as it was alive.
So it is as yet unclear whether an abortion would have had any material benefit in terms of reducing Savita Halappanavar's risk of infection and subsequent death. Had an abortion been performed before infection had set in, it is possible the risk of infection would have been reduced. If she was already infected by the time she presented at the hospital, it is possible an abortion would have had no material benefit. However that would also raise the question as to whether her infection was diagnosed and treated quickly and aggressively enough.
These issues can ultimately only be resolved by a minute examination of the medical records and interviews with the staff involved by the inquiry team. That is not to say, however, that the Savita Halappanavar case does not highlight a number of very troubling issues for the health of women who suffer complications during pregnancy in Ireland.
Irish women report many instances of being forced to carry unviable or naturally aborted foetuses to spontaneous abortion or even to term - a situation that many describe as traumatic. The lack of ethical guidelines clearly disposes doctors to take the road of least intervention and legal risk. Some may vaguely suggest that the women might consider traveling to England for treatments they are not in a position to provide. That option, is, of course, only realistic for women of means. Some report the additional trauma of having to travel to England without adequate support and whilst feeling unwell. Others report the utter inappropriateness of receiving the ashes of their unborn child in the post some time after their termination.
What happens, for instance, if a mother discovers she is pregnant and has cancer at more or less the same time, and needs urgent chemo and radiotherapy to improve her 5 year survival chances? The hormonal changes associated with pregnancy may even accelerate the development of cancer. However, because her condition isn't immediately life threatening she will be refused an abortion in Ireland. Some doctors may be reluctant to proceed with aggressive Chemo and Radiotherapy because of the damage it may do to the unborn child and some mothers may delay treatment until the child is born. Other doctors may suggest she travel to England and get a termination so that aggressive cancer treatment can proceed. But should a mother be expected to accept a much less than optimal medical treatment which materially effects her life expectancy if she cannot afford or does not wish to travel to England?
The bottom line is that whilst Ireland generally has a good maternity service with good outcomes for both mothers and children, when complications arise, doctors can differ, doctor's hands are sometimes tied, and the full range of medically indicated procedures are not available because some, led by the Catholic Church, believe they have a greater right to determine what the mother should do in that case than the mother herself.
Meanwhile the Government's response to the crisis is in real trouble. Following objections from Savita Halappanavar's husband, the Government has asked the members of the Inquiry team who are also members of staff of Galway University Hospital to stand down from the inquiry to improve it's standing as an independent inquiry. However Praveen Halappanavar has also insisted that the inquiry be a full public sworn inquiry with powers to compel witnesses and subpoena evidence and has stated he will withhold his permission for any inquiry to access his wife's medical records unless it meets that standard. Without those records, any inquiry would be almost pointless, so the Government may, ultimately have to concede on that point as well.
The problem is that - going on past experience in Ireland - such lawyer led inquiries cost hundreds of millions and take several years to produce a report. We need a much more immediate response to this crisis. Another problem - for the Government - is that it has emerged that the chairman of the inquiry, Prof Sir Sabaratnam Arulkumaran, is also the author of an article in the International Journal of Gynecology and Obstetrics in 2009 on safer childbirth and "reproductive rights" in which advocated for much wider availability of abortion in countries with restrictive abortion regimes. Naturally the "pro-life" movement is up in arms about his suitability for the appointment.
Sinn Fein is moving a motion in Parliament tomorrow to force the Government to act to provide a legislative basis for doctors to perform an abortion where there is a "substantive risk" to the life of the mother - in line with a 20 year old ruling of the Supreme Court on the constitution. The Pro-life movement is accusing the pro-choice activists and the media of exploiting Savita Halappanavar's death for their own purposes and the Government is urging caution in the light of the complexity of the issues which need to be dealt with. The risk is that this issue may yet be kicked into the long grass and not dealt with for another 20 years.