CONTENTS

Page

INTRODUCTION 3

INDUCED ABORTION 4
Introduction 4
Present Guidelines 4
Approach to revising guidelines 6
General background: 6
Legal background 6
The issues raised: 7
General 7
Legal and ethical permissibility 7
The clinical issues 7
The medical response 8
Would medical practice be impaired by total abortion ban 9
Negative Consequences of Abortion 11
Recommendations 13

EUTHANASIA (INCLUDING WITHDRAWAL OF FEEDING) 14

Introduction 14
General background: 14
Legal 16
Medical Council’s position 16
General background - withdrawal of feeding: 19
Legal 19
Medical Council’s position 19
Recommendations 21

1
IVF INCLUDING EMBRYO STORAGE AND FREEZING 22
Introduction 22
More recent developments 22
Are there particular issues to be addressed by the Council? 22
Control of IVF by Council 23
General considerations 23
Inadequacy of pre-1998 Guidelines 23
Treatment of certain embryos 23
Should embryo freezing or storage be permissible? 24
The 2004 Guidelines 24.1, 24.2, 24.3, 24.4, 24.5 25
Guidelines 24.5 on In Vitro Fertilisation 25
Recommendations 26

OTHER MATTERS 27
Abortion Assistance & Referral 27
Introduction 27
General background: 27
Legal 27
The Abortion Information Act, 1995 27
Abortion Information Act - provisions and interpretation 27
Contradiction 28
Dual Patient model 29
Recommendations 29

SUMMARY OF RECOMMENDATIONS 30

CONCLUSION 32

2
 INTRODUCTION

The Pro-Life Campaign is a non-denominational lobby group drawing its

support from a wide cross-section of Irish society. The Campaign promotes
pro-life education and defends human life from unjust attack at all stages,
from conception to natural death. It also campaigns for resources to support
and assist pregnant women and those in need of healing after abortion.

This submission to the Ethics Committee of the Medical Council deals with
five major areas: abortion, abortion assistance, euthanasia and the withdrawal
of feeding and the protection of human embryos.

Each chapter of the submission is laid out in a similar format – a short general
introduction setting the background to the chapter topic, followed by more
detailed background information and an ethical and legal appraisal of the
issues raised therefrom.

Each chapter ends with a number of short recommendations that the Pro-Life
Campaign would urge the Ethics Committee to adopt in its revision of the
Medical Council’s A Guide to Ethical Conduct and Behaviour and to Fitness to
Practice.

3
 INDUCED ABORTION
Introduction
In Ireland, the unborn child has for centuries been regarded as worthy of legal
protection. The Offences Against the Person Act 18611 prohibits abortion
under threat of penal sanction. In the 1983 referendum, the people approved
the insertion of Article 40.3.3o (the Eighth Amendment) into the Constitution
whereby “the State acknowledges the right to life of the unborn and, with due
regard to the equal right to life of the mother, guarantees in its laws to respect
and, as far as practicable, by its laws to defend and vindicate that right”. Given
the circumstances of the insertion of this assertive amendment into the
Constitution, it was considered at the time to copperfasten the legal prohibition
on induced abortion. However, following the decision of the Supreme Court in
the Attorney General v X and others (1992)2 it now appears that induced
abortion, in certain circumstances, is lawful in this jurisdiction. However, the X
case judgement is notoriously difficult to interpret as a basis for legislation.
The commendable attempt to correct the situation in the March 2002
referendum failed, amid unparalleled public confusion, but the result clearly
showed a national majority opposed to induced abortion in the Republic under
any circumstances.

Present Guidelines

The 1998 Ethical Guidelines of the Medical Council on induced abortion

(Section 26.5) read:

The Child In Utero

The deliberate and intentional destruction of the unborn child is

professional misconduct. Should a child in utero suffer or lose its life
as a side effect of standard medical treatment of the mother, then this
is not unethical. Refusal by a doctor to treat a woman with a serious

1
Sections 58 and 59.
2
1992 1 IR 1.

4
 illness because she is pregnant would be grounds for complaint and
could be considered to be professional misconduct.

That guideline was a satisfactory and concise statement of the principles

involved. It is unusual for guidelines to be changed in a Council’s mid-term,
especially when there is no pressing need to do so. However, after a bizarre
series of divisive confrontations in 2001, the Council altered Section 26.5 of
the 1998 Guide on 12th September 2001 to read as follows (which then
became Section 24.6 of the 2004 Guidelines):

The Child In Utero

The Council recognises that termination of pregnancy can occur when

there is a real and substantial risk to the life of the mother and
subscribes to the views expressed in Part 2 of the written submission of
the Institute of Gynaecologists and Obstetricians to the All-Party
Oireachtas Committee on the Constitution as contained in the Fifth
Progress Report, Appendix IV, page A407.

This is reinforced by Clause 24.1 in the present 2004 Guidelines.

This is not as clear a statement of principle as what it replaced but is

acceptable in light of the meaning of the Obstetricians and Gynaecologists
statement on which it relies. It is important to note that termination of a
pregnancy is not the termination of a life where the child is deliberately
targeted, disregarding, of course, the common usage of that word. Births and
caesarean sections terminate pregnancies as do interventions in eclampsia,
pre-eclampsia et cetera, but they do not deliberately terminate lives.

5
Approach to revising Guidelines

The PLC suggests to the Medical Council that the revision of the Ethical
Guidelines be approached from the following standpoint:

1. The recognition that human life, born or unborn, is worthy of protection;

2. The presumption that in pregnancy the doctor has a duty of care towards
two patients, the mother and the unborn child.

3. That the availability of induced abortion is a social question, not one of

medical necessity;

4. That the onus of proof is upon those who propose induced abortion to
produce evidence that there is no absolutely alternative.

In the light of this, the Pro-Life Campaign suggests that the following additions
to the Guide may clarify the matter beyond even unreasonable doubt:

1. A positive re-statement of the line that in pregnancy the doctor has a duty
of care towards two patients, the mother and the unborn child;

2. An affirmation of the principle that necessary treatments which carry a risk

of unsought side effects are ethical even when the unsought effects are
foreseeable, while procedures the purpose of which are to cause the death
of a patient are unethical.

General Background

The Legal Background

Notwithstanding the statutory prohibition on abortion contained in the
Offences Against the Person Act 1861 and the terms of the Eighth
Amendment to the Constitution, in X – a 1992 case (involving a minor’s
alleged suicidal intentions) – the Supreme Court concluded

“that the proper test to be applied is that if it is established as a

6
 matter of probability that there is a real and substantial risk to the
life, as distinct from the health, of the mother, which can only be
avoided by the termination of her pregnancy, such termination is
permissible, having regard to the true interpretation of Article
40.3.3. of the Constitution.”

The rest of the Supreme Court judgements in X offer no guidance as to how

this opaque ‘test’ is to be applied in practice. Nor did the Court consider – nor
did it have the opportunity to consider – the clinical reality of induced abortion
known at that time and since articulated in Medical Council ethical guidelines.

Since that case, different Governments took different approaches to the issue.
Following the rejection of the November 1992 referendum that allowed for
direct abortion along the lines envisaged in X (excluding suicide threats); A
commitment to legislate for X was later recognised as ‘very difficult, if not
impossible’3 and the commitment was dropped from subsequent programmes
for government. The narrow rejection of the 2002 Referendum indicated that
there was a majority opposed to induced abortion being carried out in Ireland
in any circumstances and also showed great concern for unimplanted human
embryos.

The Issues Raised

General
It is widely accepted that good ethical medical practice must always be based
upon principle. Ad hoc arrangements rather than responses based on
principle and ethics for dealing with any given situation could readily lay the
medical profession open to the charge of inconsistency at least and of being
self-serving at worst and would threaten the profession’s deserved reputation
for impartiality and the provision of medical care regardless of the class,
creed, lifestyle and ethnic origins of the patient and the doctor’s own personal
feelings towards him or her.

3
Health Minister Brendan Howlin, The Irish Times, 25 November 1994

7
Legality and Ethical Permissibility
The rule of law aims to serve society at large, while simultaneously upholding
the rights of the individual, insofar as they do not conflict with essential
societal interests. Whereas some unethical acts may be illegal, legality alone
does not determine whether a practice is ethical or not.

The Council’s 1994 Guidelines emphasised that:

“In this whole area of conflicting attitudes [referring to reproductive
medicine generally], doctors while obeying the laws of the State,
must always be guided by their own informed consciences.”

And the 1998 & 2004 guideline, now in force, holds the same
independent line:
“Medical care must not be used as a tool of the State, to be
granted or withheld or altered in character under political pressure.
Doctors require independence from such pressures in order to
carry out their duties. Regardless of their type of practice, the
responsibility of all doctors is to help the sick and injured. They
must practice without consideration of religion, nationality, gender,
race, politics or social standing. They must not allow their
professional actions to be influenced by any personal interest”.

The Clinical Issues

The most frequent arguments for induced abortion in the debate since 1992
are the supposed risks to the health or life of the mother. Other arguments
e.g. congenital handicap in the unborn child or the economic burden to
society, raise broader issues. As such, although the Pro-Life Campaign
similarly opposes such arguments, for the purposes of this submission, they
fall outside the parameters of the medical debate on induced abortion and
have no bearing on the right to life of the mother.

The Medical Response

The issue of whether induced abortion is in some cases necessary to save a

mother’s life or health has been discussed extensively. As the Medical

8
Council’s 1994 Guidelines pointed out, no evidence has been produced to
support this position. The Pro-Life Campaign has continued to monitor the
national and international literature on the topic, and is satisfied that this
remains the case. By the word “abortion”, the Pro-Life Campaign means
induced abortion directly and deliberately targeting the life of the unborn child,
not where the unborn child is indirectly affected by proportionate and
necessary treatment of the mother. Deliberately induced abortion has no
place in the treatment of any maternal condition, either physical or
psychological.

Would medical practice be inhibited by a complete prohibition on

induced abortion?

Concern was expressed that a medical practitioner may find himself/herself

falling foul of a total professional or legal prohibition on induced abortion in the
ordinary course of good ethical clinical practice. In our view, such concerns
are unfounded.

Foreseeability is not the test of intention in a prohibition on induced abortion.

In everyday clinical practice, harm or injury to a patient is readily foreseen as
a consequence of medical intervention. Nevertheless, especially in instances
of life-threatening conditions, it is perfectly permissible to use treatments that
are associated with serious or even life threatening side effects. In such
circumstances, the doctor’s judgement may well be that it is proper to incur
grave risks in the management of grave conditions. For example, in the
treatment of leukaemia, induced myelosuppression exposes the patient to
risks of overwhelming sepsis and severe haemorrhage. Nevertheless, in the
circumstances, such risks are assessed as acceptable in terms of the desired
outcome of cure. However, the medical and ethical principle governing such
decisions is that the therapeutic option chosen must be the most effective and
least toxic. Thus, if there are two treatments, Treatment A and Treatment B, of
equivalent therapeutic efficacy, the ethical obligation is to choose the one
associated with the least severe side effects. This is an essential component
of ethical practice but does not, of itself, preclude running serious risks in
grave conditions.

9
In summary, the risks of treatment must be proportionate to the condition
being treated. In pregnancy, where uniquely, there is a simultaneous duty to
two patients, a fortiori, these considerations apply – with due regard to side
effects not alone to the mother but also to her unborn child. In no
circumstances, however, is it permissible to compromise the therapeutic
objective merely by virtue of the mother’s pregnancy. In this regard, the
Council’s current position on induced abortion reflects the reality but could be
strengthened to make the principles more explicit and clarify them. .

Foreseeability, in effect, is merely a matter from which, depending on the

circumstances, an inference of intention may be drawn. However, it does not
follow that an act which causes the foreseeable death of a patient may be
excused, merely because what was intended was the relief of some condition,
e.g. severe pain or depression. Thus, if the death of the patient was a
‘treatment’ or an intrinsic part of the ‘treatment’ of the condition in question,
liability, both ethical and legal, attaches.

A clear judicial expression of the underlying principle, in a case involving a

charge of attempted murder of a patient by her consultant physician, which
encapsulates the essentials of ethical (and lawful) treatment was stated thus:

“We all appreciate … that some medical treatment, whether of a

positive, therapeutic character or solely of an analgesic kind …
designed solely to alleviate pain and suffering, carries with it a
serious risk to the health or even the life of the patient. Doctors …
are frequently confronted with, no doubt, distressing dilemmas.
They have to make up their minds as to whether the risk, even to
the life of their patient, attendant upon their contemplated form of
treatment, is such that the risk is or is not medically justified. Of
course, if a doctor genuinely believes that a certain course is
beneficial to his patient, either therapeutically or analgesically, even
though he recognises that that course carries with it a risk to life, he
is fully entitled, nonetheless to pursue it. If sadly, and in those
circumstances the patient dies, nobody could possibly suggest that
in that situation the doctor was guilty of murder or attempted
murder. …

10
 There can be no doubt that the use of drugs to reduce pain and
suffering will often be fully justified notwithstanding that it will, in
fact, hasten the moment of death, but … what can never be lawful
is the use of drugs with the primary purpose of hastening the
moment of death. … It matters not by how much or by how little [a]
death is hastened or intended to be hastened … even if [it be the
case that death was only hours or minutes away] no doctor can
lawfully take any step deliberately designed to hasten that death by
however short a period of time. … Alleviation of suffering means
the easing of it for so long as the patient survives, not the easing of
it in the throes of and because of deliberate purposed killing.”4

There is no reason to suggest that the courts in this jurisdiction would differ
from this statement of the law in its articulation of the underlying principles in
relation to the death of an unborn child during the course of the treatment of
an ill mother especially given the delimitation on the vindication of the right to
life of the unborn by considerations of reasonable practicability. The approach
that informs the Medical Council’s 1998 Guidelines on induced abortion also
reflects the principles underlying this analysis and again urges its retention.

Negative consequences of abortion

Rather than encourage abortion, the medical profession has a responsibility to

take seriously the growing body of evidence showing the negative after-effects
of abortion on women. Most early studies of the effects of abortion on women
were limited to the immediate post-abortion period. Now long-term studies are
giving a clearer picture. One such study was published in 2006 in the Journal
of Child Psychology and Psychiatry.5 This was a 25 year longitudinal study
which showed that women having an abortion had elevated rates of
subsequent mental health problems including depression, anxiety, suicidal
behaviours and substance use disorders. This association persisted after
adjustment for confounding factors. The main author of this New Zealand

4
R v Cox 12 BMLR 38 (Winchester Crown Court per Ognall J and approved in Airedale NHS
Trust v Bland 1993 1 All ER 821 (HL).
5
Fergusson DM, Horwood LJ, Ridder EM, Abortion in young women and subsequent mental
health, Journal of Child Psychology and Psychiatry, 47 (2006), 1: 16-24.

11
study, Prof. David Fergusson admitted: “I’m pro-choice but I’ve produced
results which, if anything, favour a pro-life viewpoint”.

An earlier study in Finland6 examined data from 1987-2000 and highlighted

the fact that the suicide rate was almost seven times higher in women who
had abortions compared to those who gave birth. This is particularly relevant
to the Irish situation given the calls for abortion to be legalised on grounds of
threatened suicide. A recent Norwegian study found that women after induced
abortions suffered more long-term after effects than those who had
miscarriages. 7

These latest findings oblige medical practitioners to give full information to

patients about the medical consequences of abortion.

6
Mika Gissler, Cynthia Berg, Marie-Hélène Bouvier-Colle, and Pierre Buekens, Injury deaths,
suicides and homicides associated with pregnancy, Finland 1987-2000, The European
Journal of Public Health 2005 15: 459-463.
7
Anne Nordal Broen, Torbjørn Moum, Anne Sejersted Bødtker and Øivind Ekeberg, The
course of mental health after miscarriage and induced abortion: a longitudinal, five-year
follow-up study, BMC Medicine 2005, 3:18

12
Recommendations

That the revised Ethical Guidelines maintain the formulation of 12th September 200 1,
Clause 24.6 and 24.1 in 2004 guidelines, but, in other clauses, assert:

1. The principle that in pregnancy the doctor has a duty of care towards two patients,
the mother and the unborn child;

2. The principle that necessary treatments which carry a risk of unsought side effects
are ethical, even when the unsought effect is foreseeable, while procedures the
purpose of which are to cause the death of a patient are unethical.

3. Induced abortion does not constitute “medical treatment” in any circumstances.

4. Therapeutic convenience is never a sufficient justification for induced abortion and

the adoption of such an approach is unethical.

5. Medical ethics do not follow each change in the law and mere legality is not
equivalent to ethical practice.

6. A prohibition on induced abortion is both feasible and ethically necessary, and has
not resulted in the treatment appropriate for the management of any ill mother
being compromised in any way.

13
 EUTHANASIA

Introduction

In 1994, the Medical Council in A Guide to Ethical Conduct and Behaviour and
to Fitness to Practise stated its position in relation to euthanasia as defined
therein. The Pro-Life Campaign welcomes the evolution of the Council’s
treatment of the issue over the past fifteen years and specifically endorses the
approach, which firmly places a prohibition on a medical practitioner’s
involvement in euthanasia within an ethical framework irrespective of what the
current legal situation might be. The Pro-Life Campaign urges the Medical
Council to re-assert the traditional opposition of the medical profession to
euthanasia and to further strengthen the profession’s protection of chronically
and terminally ill patients by stressing the relevance both of intention and
directness in the prohibition of killing, or causing the deaths of, such patients.
In the 1998 Guidelines, the principles are adequately covered in Sections 24
& 25 and in the 2004 Guidelines in Sections 22.1 and 23.1.

General Background - Euthanasia

The Legal Background

Euthanasia is, and has always been, illegal in Ireland. Involving, for medical
practitioners, as it does, the direct and intentional killing of a patient, it falls
within the general prohibition on homicide within the general law. Thus, briefly
put, a person is guilty of murder if (s)he, while intending to kill another or to
cause him or her serious injury, acts in a way that results in that other
person’s death within a year and a day of the date upon which the injury was
inflicted. However, because of a curious anomaly in the law, omissions that
have the same effect, except in certain limited circumstances, do not result in
criminal liability. In this regard, the law presumes (although it is a refutable
presumption) that a person intends the natural and probable consequences of
his or her actions8 (as distinct from omissions).

8
Criminal Justice Act 1964 s. 4.

14
However, that is not to say that foreseeability, in this context, is the test of
intention. Interestingly, the principle which underlines the treatment of
terminally ill patients is the same as that which governs the treatment of
illness in pregnant women, and would equally benefit from an explicit
affirmation that necessary treatments which carry a risk of unsought side
effects are ethical, even when the unsought effect is foreseeable, while
procedures which lead directly and intentionally to a patient’s death are
unethical.

In this regard, the Pro-Life Campaign herein repeats the arguments advanced
in considering procedures to save a pregnant woman’s life, which may
indirectly damage the unborn child. Thus, in everyday clinical practice, harm
or injury to a patient is readily foreseen as a consequence of each and every
diagnostic or therapeutic intervention. Nevertheless, in instances of serious or
life-threatening conditions, it is perfectly permissible to use treatments that
carry a risk of serious or even life threatening side effects. In such
circumstances, the doctor’s judgement may be that it is proper to incur grave
risks in the management of grave conditions. Thus, for example, in the
treatment of leukaemia, induced myelosuppression exposes the patient to the
risks of overwhelming sepsis and severe haemorrhage. Nevertheless, in the
circumstances, such risks are deemed acceptable in terms of the desired
outcome. However, what is intrinsic to such treatment decisions is that the
therapeutic option chosen must be the most effective and least toxic. Thus, if
there are two treatments, Treatment A and Treatment B, of equivalent
therapeutic efficacy, the ethical obligation is to chose that which is associated
with the least severe side effects. This is an essential component of ethical
practice but does not, of itself, preclude running serious risks in grave
conditions. In summary, the risks of treatment must be proportionate to the
condition being treated.

Foreseeability, in effect, is merely a matter from which, depending on the

circumstances, an inference of intention may or may not be drawn. However,
it does not follow that an act that causes the foreseeable death of a patient
may be excused, merely because what was intended was the relief of some
condition, e.g. severe pain or depression. Thus, if the death of the patient was
a ‘treatment’ or an intrinsic part of the ‘treatment’ of the condition in question,
the doctor would have moral and legal culpability for the death.

15
It has already been proposed in this submission that this principle might be
usefully incorporated in the section of the Guide pertaining to Ethical Conduct.
It is also worth reiterating the clear judicial expression of the underlying
principle, in a case involving a charge of attempted murder of a patient by her
consultant physician, which encapsulates the essentials of ethical (and lawful)
treatment was stated thus:

“We all appreciate … that some medical treatment, whether of a

positive, therapeutic character or solely of an analgesic kind …
designed solely to alleviate pain and suffering, carries with it a
serious risk to the health or even the life of the patient. Doctors …
are frequently confronted with, no doubt, distressing dilemmas.
They have to make up their minds as to whether the risk, even to
the life of their patient, attendant upon their contemplated form of
treatment, is such that the risk is or is not medically justified. Of
course, if a doctor genuinely believes that a certain course is
beneficial to his patient, either therapeutically or analgesically, even
though he recognises that that course carries with it a risk to life, he
is fully entitled, nonetheless to pursue it. If sadly, and in those
circumstances the patient dies, nobody could possibly suggest that
in that situation the doctor was guilty of murder or attempted
murder. …

There can be no doubt that the use of drugs to reduce pain and
suffering will often be fully justified notwithstanding that it will, in
fact, hasten the moment of death, but … what can never be lawful
is the use of drugs with the primary purpose of hastening the
moment of death. … It matters not by how much or by how little [a]
death is hastened or intended to be hastened … even if [it be the
case that death was only hours or minutes away] no doctor can
lawfully take any step deliberately designed to hasten that death by
however short a period of time. … Alleviation of suffering means

16
 the easing of it for so long as the patient survives, not the easing of
it in the throes of and because of deliberate purposed killing.”9

As already suggested, there is no reason as to why the approach of the courts

in this jurisdiction would differ from this statement of the law in its articulation
of the underlying principles in relation to euthanasia, especially given the
constitutional guarantees of the right to life of the citizen.
Council’s Position

The Medical Council, in A Guide to Ethical Conduct and Behaviour and to

Fitness to Practise has repeatedly asserted the duties of medical practitioners
in regard to dying patients. Thus, for example, in the 1984 edition of the guide,
it asserted:

“Where death is imminent, it is the doctor’s responsibility to take

care that a patient dies with dignity and with as little suffering as
possible. Euthanasia involves actively causing the death of a
person and is illegal.”

In the 1989 edition the final sentence of this statement was amended to read:
“Euthanasia, which involves actively causing the death of a person,
is illegal in Ireland and is professional misconduct.
In the 1994 edition, the final sentence was further amended as follows:

“Euthanasia, which involves deliberately causing the death of a

patient, is professional misconduct and is illegal in Ireland.”
This was strengthened in the 1998 edition.

In the 2004 edition, the prohibition on euthanasia is contained in two

sections:

22.1 For the seriously ill patients who is unable to communicate or

9
R v Cox 12 BMLR 38 (Winchester Crown Court per Ognall J and approved in Airedale NHS
Trust v Bland 1993 1 All ER 821 (HL).

17
 understand, it is desirable that the doctor discusses management
with the next of kin or the legal guardians prior to reaching a
decision about the use or non-use of treatments which will not
contribute to recovery from the primary illness. In the event of
a dispute between doctors and relatives, a second opinion should
be sought from a suitably qualified independent medical
practitioner.
Access to nutrition and hydration remains one of the basic needs
of human beings, and all reasonable and practical efforts should
be made to maintain both of them.

23.1. Where death is imminent, it is the responsibility of the doctor

to take care that the sick person dies with dignity, in comfort, and
with as little suffering as possible. In these circumstances, a
doctor is not obliged to initiate or maintain a treatment that is futile
or disproportionately burdensome. Deliberately causing the death
of a patient is professional misconduct.

It is clear from both the precision of the definition of euthanasia which has
evolved in the Medical Council’s guide over the past fifteen years, which
avoids doubt as to the subject matter of the prohibition, and the firm placing of
that prohibition within an ethical, as distinct from a solely legal, framework,
that the Medical Council was properly concerned with euthanasia as an
ethical issue, quite irrespective of what the prevailing law might happen to be.

Indeed, the Medical Council has gone further in this regard. In a statement
issued by the Council after its statutory meeting on August 4, 1995, the
Council drew attention to, and emphasised other provisions of the 1994 guide.
Thus, the Council noted paragraph 13.01 which states inter alia:

“ … Doctors must do their best to preserve life and promote the

health of the sick person …
and paragraph 12.05; of the 1994 Guide as follows:

“Medical care must not be used as a tool of the State to be granted

18
 or withheld or altered in character under political pressure,
Regardless of the type of their practice, the responsibility of all
doctors is to help the sick and injured. Doctors must practise
without consideration of religion, nationality, race, politics or social
standing. Doctors should not allow their professional actions to be
influenced by any personal interest”

The Council also drew attention to the provisions of Article 2 of the Principles of
Medical Ethics in Europe which states:

“In the course of his professional practice a doctor undertakes to

give priority to the medical interest of the patient. The doctor may
use his professional knowledge only to improve or maintain the
health of those who place their trust in him; in no circumstance may
he act to their detriment.”

and to Article 4 which states inter alia:

“ …The doctor must not substitute his own definition of the quality
of life for that of his patient….”

General Background – Withdrawal of feeding

On July 27, 1995, a majority of the Supreme Court upheld an earlier order of
the High Court that it was lawful to withdraw feeding from a seriously
handicapped woman – described as being in a ‘near permanent vegetative
state’ - in order that she might die.10 Although similar problems had previously
come before the courts in other jurisdictions, this was the first such case in
Ireland and focused attention not alone on an intensely difficult human
dilemma but also on conflicts between medical and legal analyses of the
same issues.
At its statutory meeting on August 4, 1995, the Medical Council considered
the decision of the Supreme Court in re a Ward of Court. In a statement

10
In the matter of A Ward of Court (withholding medical treatment) (No. 2) [1996] 2 IR 100.

19
issued after the meeting, the Medical Council drew attention to A Guide to
Ethical Conduct and Behaviour and to Fitness to Practise and, having
emphasised a number of particular paragraphs, already set out above, in
relation to a medical practitioner’s duty of care and euthanasia, stated:

“It is the view of the Council that access to nutrition and hydration is
one of the basic needs of human beings. This remains so even
when, from time to time, this need can only be fulfilled by means of
long established methods such as nasogastric and gastrostomy
tube feeding.
The Council sees no need to alter its Ethical Guide.”

The Pro-Life Campaign wholly endorses the position adopted by the Medical
Council and urges the express re-affirmation of the underlying principle in the
revised Guidelines.

20
Recommendations

That the revised Ethical Guidelines assert:

1. The prohibition on euthanasia, in the clear and robust terms of the 1998 and 2004
Guides.

2. A re-statement of the Medical Council’s position on the withdrawal of feeding in line

with its statement of August 4, 1995.

3. A continuation of the Medical Council’s independent stance on the issues of

euthanasia and the withdrawal of feeding notwithstanding the effective change in
the law in relation to euthanasia consequent on the decision of the Supreme Court
in the Ward case.

4. An express statement that any complicity of a medical practitioner in the

withdrawal of feeding from a chronically ill patient with the intention or purpose that
the patient will die as a result is unethical and will attract such sanctions as the
Medical Council sees fit to impose.

5. An affirmation, (perhaps in the section on Ethical Conduct), of the principle that

necessary treatments that carry a risk of unsought side effects are ethical, even
when the unsought effect is foreseeable, while procedures intended to cause the
death of a patient are unethical.

21
 IVF INCLUDING EMBRYO FREEZING AND STORAGE

Introduction

On the 31st May 1985, it was reported in the medical press that three Irish
women had been successfully implanted in Ireland with ova fertilised in vitro.
The work, carried out by Prof. Robert Harrison, Consultant Gynaecologist, in
St. James'
s Hospital and Sir Patrick Dun'
s Hospital involved two campuses, as
equipment in each was essential.

In July 1985, the then Minister for Health, Barry Desmond, announced in the
Dáil that his department would examine the issue with a view to legislation.
One month later, in August 1985, a conference on the ethical and legal issues
in IVF was held in Maynooth. The Board of St. James' s Hospital imposed a
moratorium on further IVF work in St. James' s, pending the outcome of an
inquiry by a Board sub-committee into the matter. The Medical Council, by a
majority decision in December 1985 approved the guidelines on IVF
promulgated by the Institute of Obstetricians and Gynaecologists of the Royal
College of Physicians of Ireland.11 This effectively delayed the re-introduction
of IVF in St. James’s until January 1986 at which point, however, the IVF
debate in Ireland, what little there was, had been effectively completed.

The Medical Council subsequently approved the therapeutic application to

married couples of the revised guidelines on IVF of the Institute of
Obstetricians and Gynaecologists of the Royal College of Physicians of
Ireland.12

More Recent Developments

By 1998, it increasingly appeared from the medical press that embryo storage
was considered desirable from a clinical and patient standpoint. A sub-

11
A Guide to Ethical Conduct and Behaviour and to Fitness to Practise (Third Edition)
approved by the Medical Council at its meeting on 7th October 1988 and published in March
1989.
12
A Guide to Ethical Conduct and Behaviour and to Fitness to Practise (Fourth Edition)
approved by the Medical Council at its meeting on 1st October 1993 and published in January
1994

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committee of the Institute of Obstetricians and Gynaecologists of the Royal
College of Physicians of Ireland met to review its guidelines on IVF and as it
reached no agreed conclusions its Report was not published. In the meantime
the HARI Unit at the Rotunda Hospital in Dublin unilaterally proceeded with
freezing human embryos and even allegedly had clients sign “agreements”
that “unwanted human embryos” would be destroyed after five years. This
would, of course, be clearly unethical, illegal and opposed to the present
Guidelines. Clearly, the issue of freezing and storage of human embryos, as
opposed to the freezing of sperm and ova, will have to be seriously addressed
by the Medical Council and sanctions imposed. It is in this context and in the
context of disturbing and uncontroverted media reports regarding abuses in
IVF in Ireland that the Pro-Life Campaign makes this submission to the
Medical Council.

The inadequacy of previous guidelines

It is of great concern that the guidelines promulgated by the Institute of
Obstetricians and Gynaecologists of the Royal College of Physicians of Ireland
and approved by the Medical Council in 1994 were merely exhortatory in
nature. The language, couched in subjunctives and in terms of proposed and
recommended best practice, seemed devoid of any imperative force and
apparently relied on a benign self-regulatory environment for adherence.
There were significant changes between the guidelines in the 1989 and 1994
editions of the Medical Council’s Guide to Ethical Conduct and Behaviour and
to Fitness to Practise. For example, guideline number 2 in the 1994 edition
provided as follows:

“All fertilised embryos produced by IVF should be replaced, optimally this

should be three in any treatment cycle”

whereas the previous guideline required that

“All fertilised embryos produced by IVF should be replaced in the potential

mother' s uterus.”

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Leaving to one side the slightly difficult concept of who constitutes a “potential
mother” in this context, given what has gone before, the fact of the deletion to
the ‘mother’s uterus’ cannot be wholly without effect.

Should embryo storage or freezing be permissible?

Rapidly developing technologies and the willingness of certain practitioners to
seek loopholes in the Ethical Guidelines make this revision particularly
relevant.

A definitional problem arises in respect of what constitutes, what is unhappily

referred to as, a ‘spare embryo’. Thus, it is unclear as to whether it represents
the excess above the three that it is recommended be implanted in any given
treatment cycle or an embryo which is simply surplus to requirements, at the
election of either of the ‘parents’ or IVF medical specialist. Unfortunately, the
exhortatory language used in 1994 made it difficult to interpret this provision.
There was concern that the guidelines raised the possibility that there was a
difference between a fertilised ovum and an embryo. There was further
concern that the guidelines did not contain an express prohibition on research
on embryos not produced specifically for that purpose and on the storage of
embryos for any purpose.

In this context, any express and favourable consideration of proposals for the
storage or freezing of human embryos by the Medical Council would
compound the underlying unsatisfactory nature of the regulation of IVF in
Ireland. Moreover, it would further compromise the right to life of countless
further embryos by exposing them to conditions minimising or significantly
reducing their chances of survival.

It is disingenuous to justify the storage or freezing of human embryos on the

basis that it is either ‘pro-life’ or represents a ‘pro-life strategy’. Apart from the
very dramatic lessons that can be learned from the British experience in this
regard, the storage of a human embryo is not ‘pro-life’ – it merely tolerates the
existence of the unborn human involved without respecting its right to life and,
in circumstances where there is no guarantee that its right to life will ever be
respected. In the circumstances, the storage of human embryos is
fundamentally violative of the constitutionally protected right to life of the

24
unborn enshrined in the Eighth Amendment of the Constitution. The Medical
Council might consider adopting, as a statement of ethical principle, the
affirmation at its April 1996 Annual General Meeting by the Irish Medical
Organisation that the freezing of embryos is inconsistent with the medical
profession’s long-held tradition of respect for human life at all stages of
development.

The R versus R case before the Supreme Court will examine the current legal
status of frozen human embryos but, as stated already, the courts determine
what is legal, not what is ethical. Hence whatever the decision of the court in
this matter it will not negate the ethical requirement for respect of all life from
conception to natural death.

THE CURRENT 2004 GUIDELINES

24.1 In this rapidly evolving and complicated area the Council reminds
doctors of Reproductive Medicine their obligation to preserve life and to
promote health. The creation of new forms of life for experimental
purposes or the deliberate intentional destruction of human life already
formed is professional misconduct.

24.4 Frozen Sperm and Ova

There is no objection to the preservation of sperm or ova to be used

subsequently on behalf of those from whom they were originally taken.
Doctors who consider assisting with donation to a third party must have
regard to the biological difficulties involved and pay meticulous attention
to the source of the donated material. Doctors who fail to counsel both
donor and recipient thoroughly about the potential social, medical and
legal implications of such measures and the possible consequences for
the would-be parents and their baby could face disciplinary
proceedings.

24.5 In Vitro Fertilisation (IVF)

Techniques such as IVF should only be used after thorough
investigation has failed to reveal a treatable cause for the infertility.

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 Prior to fertilisation of an ovum, extensive discussion and counselling is
essential. Any fertilised ovum must be used for normal implantation and
must not be deliberately destroyed.
If couples have validly decided they do not wish to make use of their
own fertilised ova, the potential of voluntary donation to other recipients
may be considered.

The last paragraph in the 2004 Guidelines contradicts the essence of the 1998
guidelines in that it implies acceptance of freezing embryos where the 1998
guidelines did not. This paragraph should be dropped from the new guidelines.
The new guidelines should also clarify that using human embryos as a source
of stem cells either for research or therapeutic purposes is unethical as it
constitutes an attack on the life of the embryo.

After all, there can be no doubt that the human embryo is alive and unborn.
The embryo is not potential human life - it is human life with potential, albeit
fragile and dependent. The suggestion that an embryo should only enjoy
protection rights when implanted in a woman' s womb is arbitrary and ignores
the fact that each of us began our life as a human embryo.

Recommendations

That since IVF is at present under-regulated and its control is left to the vagaries of
the individual practitioners whose activities cannot be controlled, the revised Ethical
Guidelines, should include the content of 24.2, 24.3 and 24.7 should also assert

1. A prohibition on freezing and deletion of last paragraph of current Clause 24.5:

2 A prohibition on the placing of embryos in a part of the woman’s body where it is

anticipated that they will not survive.

3 A prohibition on embryo storage or freezing, accompanied by notice of

appropriate powers of inspection and applicable sanctions.

4 A prohibition on embryo research or the use of human embryos as a

source of stem cells for research or therapy.

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 OTHER MATTERS
Abortion Assistance and Referral
Introduction

All editions of the Medical Council’s Guide to Ethical Conduct and Behaviour
and to Fitness to Practise are opposed to induced abortion. In this submission,
the Pro-Life Campaign sets out why opposition to induced abortion should
logically apply also to abortion assistance and referral. There is a clear ethical
and logical, if not legal, dichotomy between having abortion in Ireland unethical
and at the same time allowing medical practitioners to actively assist having
unborn children aborted outside the State.

In 1995 the Oireachtas passed the Regulation of Information (Services

Outside State for Termination of Pregnancies) Bill 1995 (referred to as the
Abortion Information Act). The President referred the Bill to the Supreme Court
to consider its constitutionality, which subsequently ruled that it was
constitutional.

The Act provides for the giving of ‘Act information’, i.e. information likely to be
required by a woman to avail of services provided outside the State for the
termination of pregnancies. This information relates to such services and to
the persons who provide them,13 given by a person who engages in, or holds
himself out as engaging in, the activity of giving information, advice or
counselling to individual members of the public in relation to pregnancy.14
‘Termination of pregnancies’ is defined as the intentional procurement of
miscarriages of women who are pregnant’

Although the Act provides that it is unlawful for a person, upon a request to
give information, advice or counselling in relation to the particular
circumstances of a pregnant woman, to advocate or promote the termination
of her pregnancy, the giving of ‘Act information’ is perfectly lawful, subject to
certain conditions. In this regard, the Supreme Court noted that:

13
s. 2.
14
s. 1.

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 “Constitutional justice requires that in the giving of such information,
counselling and advice regard be had to the rights of persons likely to be
affected by such information, counselling and advice.”15

Furthermore, it provides that whereas it is unlawful for the persons giving the
‘Act information’ to make an appointment or any other arrangement for, or on
behalf, of a woman with a person who provides abortion services outside the
State, it was held by the Supreme Court that this provision

“ ... does not preclude [a doctor] once such appointment is made from
communicating in the normal way with such other doctor with regard to
the condition of his patient provided that such communication does not in
any way advocate or promote and is not accompanied by any advocacy
of the termination of pregnancy’16

Giving to the woman a written copy of, or the medical, surgical, clinical, social
or other records or notes, which he has in his possession relating to her, is not
prohibited by this provision.

The conscientious objection to the giving of ‘Act information’ is permitted.

Breach of the provisions of the Act constitutes an offence, punishable
summarily by a fine not exceeding £1,500.
Abortion Information Act 1995 – An Ethical Appraisal

Contradiction

There is an inherent contradiction in a system which permits a medical

practitioner, who on the one hand is required to subscribe to a professional
ethical guide that obliges that (s)he shall endeavour to preserve life and
health, to, at the same time, counsel and/or refer for the destruction of that life.

The fundamental principle of medical practice is primum non nocere – “first, do

no harm”. Because of the intimacy and dependency that underpin the doctor-

15
In Re Article 26 and the Regulation of Information (Services Outside State for Termination
of Pregnancies) Bill 1995.
16
In Re Article 26 and the Regulation of Information (Services Outside State for Termination
of Pregnancies) Bill 1995.

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patient relationship, adherence to this principle is essential to the proper
practice of medicine, breaches being punishable by professional sanction and
at law. In general, therefore, to assist in, or refer for, the destruction of the life
of any patient is ethically and legally prohibited.

Dual Patient Model

A doctor, when dealing with a pregnant mother, has two patients - the mother
and her unborn baby, and has a duty of care, both ethical, and enforceable at
law, simultaneously to each. As in any other clinical situation, a medical
practitioner cannot ignore his or her responsibilities to one patient in order
merely to satisfy the wishes of another. To deny the existence of such a duty is
to ignore the teaching of generations of obstetricians, the clear, almost
intuitive, knowledge of all parents and the reality of ever increasing medical
malpractice premia. If it is bad medicine to do, or fail to do, something which
results in damage to an unborn child en ventre sa mere how can it be good
medicine to do something which assists in procuring that child’s death? To
consider or counsel (however this counselling is done) abortion as merely one
option, from among many, which may be legitimately chosen, or to assist in, or
refer for, the destruction of the life of one patient is surely an abrogation of a
doctor’s duty to that patient.

Recommendations

That the revised Ethical Guidelines assert:

1. An ethical prohibition on abortion referral and assistance by doctors.

2. The duty of a medical practitioner to give full information to patients about the
medical consequences of having an abortion.

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 SUMMARY OF RECOMMENDATIONS

Induced Abortion

That the revised Ethical Guidelines, while maintaining the revised Section 24.6 and
24.1of the 2004 Guidelines and assert in other clauses:

1. The principle that in pregnancy the doctor has a duty of care towards two patients,
the mother and the unborn child;

2. The principle that necessary treatments which have a risk of unsought side effects
are ethical, even when the unsought effect is foreseeable, while procedures the
purpose of which are to cause the death of a patient are unethical.

3. Induced abortion does not constitute “medical treatment” in any circumstances.

4. Therapeutic convenience is never a sufficient justification for induced abortion and

that adoption of such an approach is prima facie unethical.

5. Medical ethics do not follow each change in the law and that mere legality is not
equivalent to ethical practice.

6. A prohibition on induced abortion is both feasible and ethically necessary, and has
not resulted in the treatment appropriate for the management of any ill mother
being compromised in any way.

Euthanasia

That the revised Ethical Guidelines assert:

1. The prohibition on euthanasia, in clear and robust terms of 1998 and 2004 Guide.

2. A re-statement of the Medical Council’s position on the withdrawal of feeding in line

with its statement of August 4, 1995.

3. A continuation of the Medical Council’s independent stance on the issues of

euthanasia and the withdrawal of feeding notwithstanding the effective change in
the law in relation to euthanasia by withdrawal of feeding consequent on the
decision of the Supreme Court in the Ward case.

4. An express statement that a medical practitioner’s complicity in the withdrawal of

feeding from a chronically ill patient with the intention that the patient will die as a
result is unethical and subject to disciplinary procedures by the Council.

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5. An affirmation of the principle, perhaps in the section of the Guide pertaining to
Ethical Conduct, that necessary treatments which have a risk of unsought side
effects are ethical, even when the unsought effect is foreseeable, while procedures
intended to cause the death of a patient are unethical.

Right to Life of the Human Embryo (freezing and storage)

That since IVF is at present under-regulated and its control is left to the vagaries of
individual practitioners whose activities cannot be monitored, the revised Ethical
Guidelines, should retain in essence the content of the2004 Guidelines 24.2, 24.3,
and 24.7, including the prohibition on deliberate destruction of the fertilised ovum and
also assert:

1. A prohibition on freezing embryos and deletion of final paragraph of 24.5

2 A prohibition on the placing of embryos in a part of the woman’s body where it is

anticipated that they will not survive.

3 An explicit prohibition on embryo storage or freezing, accompanied by notice of

appropriate powers of inspection and applicable sanctions.

4 A prohibition on embryo research or the use of human embryos as a source of

stem cells for research or therapy.

Other Matters

Abortion Assistance

That the revised Ethical Guidelines assert:

1. An ethical prohibition on abortion referral and assistance by doctors.

2. The duty of a medical practitioner to give full information to patients about the
medical consequences of abortion.

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 CONCLUSION

The medical Council has an enormous responsibility to promote the ethos of

care in the medical profession that respects all human life. In our democracy
based on equality before the law, some values, some rights are non-
negotiable. First among these is the right to life. Without it, all other rights are
meaningless. If the Guide to Ethical Conduct lacked clarity regarding that
most basic right, it would undermine the basis for all other self-evident rights
we cherish. Even where there is disagreement, the just response is to err on
the side of life.

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 Submission
To
Medical Council’s
Ethics Committee

Pro-Life Campaign
34 Gardiner Street Upper
Dublin 1
T: 01-8748090,
F: 01-8748094,
E: prolife@indigo.ie
6th September 2007

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34