Mairead Enright (@maireadenright)

Yesterday, the Child Care Law Reporting Project published a summary of a District Court case from 2016. A  suicidal teenager’s GP referred her to a consultant psychiatrist. She was pregnant and did not want to be. Under s. 9 of the Protection of Life During Pregnancy Act (PLDPA) the entitlement to access a life-saving abortion must be certified by three doctors (two psychiatrists, at least one of whom has experience in treating pregnant women, and an obstetrician). Their job is to assess whether there is a real and substantial risk to the woman?s life from suicide, which risk can only be averted by terminating the pregnancy. This statutory test, restrictive as it is, mirrors the 8th Amendment as interpreted in the X case – the sources of constitutional law which provide that abortion is only available in Ireland where necessary to save the pregnant woman?s life.

This girl apparently saw only one psychiatrist, who decided that, although she was suicidal and at risk of self-harm, an abortion was not ?the solution for all of [her] problems at this stage?. On his evidence, involuntary admission proceedings were begun under s. 25 of the Mental Health Act 2001 (MHA). The Health Service Executive (HSE) applied to the District Court to have the girl detained on the grounds that she was suffering from a ?mental disorder? (which meant that she was at risk of causing ‘immediate and serious harm to herself or other persons?) and required treatment which she was unlikely to receive unless such an order was made.The order was granted on the consultant psychiatrist?s evidence, and the child was detained in a psychiatric facility. We do not know what treatment it was proposed to subject her to. It was not suggested that any question arose around her capacity to consent.

At the time of making the detention order, the District Court judge appointed a guardian ad litem to represent the best interests of the child. The guardian employed another consultant psychiatrist to assess the detained girl. This second psychiatrist found that the girl was not (or was no longer) suicidal. By this point, the treating psychiatrist in the institution where the girl was detained also agreed that the initial risk of self-harm had abated. The guardian ad litem therefore applied for discharge of the detention order on the grounds that the girl was no longer suffering from a ?mental disorder? within the meaning of the 2001 Act, and so there were no grounds for her detention.

It is not known what happened to this girl after her release; whether she was facilitated to travel to seek an abortion to preserve her mental health or whether she was compelled to continue the pregnancy in Ireland. Suppose for a moment that her pregnancy was advanced, and that she was subsequently unable to travel – that she was effectively denied an abortion.  Later in the month, the Minister for Health will report on the number of abortions carried out under the PLDPA, as required by s. 15 of the Act. Refusals will not be reported, which makes it difficult to spot oppressive patterns of obstruction. This case demonstrates that the PLDPA, as it is applied in practice, is incapable of vindicating vulnerable women?s rights. There are three key points:

(i) Was the PLDPA applied here? The prominence of one psychiatrist in the report does not tell us anything by itself. S.9 of the Act says that in order to access an abortion, a woman must have been examined by 2 psychiatrists and an obstetrician; it refers to ?joint certification?. However, the Department of Health Guidance on the operation of the Act places a lot of power in the hands of the first psychiatrist. S/he may assess the patient alone, without discussion with other doctors. If s/he decides that the statutory test is not fulfilled, the pregnant person may accept that clinical recommendation. Even so, the first psychiatrist must notify the woman of the refusal in writing, of her formal right to review under s.10 of the Act and of her right to a second opinion. It not known what was done to help this, apparently very confused, child avail of those statutory rights (to advocate for her, to fill out paperwork, to clarify her choices and their consequences) once she received a first refusal. It is also important to note that this staged chain of assessment is not set out on the face of the Act – it is the Department of Health?s interpretation. It is not obvious that it is the correct interpretation of the Act: for instance it is strange that a woman?s constitutional right to a life-saving abortion can effectively be overridden by one doctor, but the right to access an abortion cannot be confirmed without the intervention of three. 

(ii) How should the PLDPA interact with the MHA? During the PLDPA debates, the Minister for Health assured the Oireachtas that a woman who did not suffer from a mental disorder within the meaning of the MHA would not be detained merely for requesting an abortion. The Department of Health must guide against any such slippage. The Department of Health Guidance on the Act does not help here. For the avoidance of doubt the guidance should clarify that the PLDPA should be considered first where possible. Even where circumstances require a pregnant person?s temporary detention, the PLDPA process should be commenced as soon as practicable. To take any other position might allow the MHA to be used to bypass the PLDPA. The MHA should not be seen as an alternative to the PLDPA even where the assessing psychiatrist guesses that a patient would not pass the test under s.9. First, if it were, the temptation to allow the MHA to become a conscientious objector?s charter in suicide cases clearly arises. The HSE should ensure that conscientious objection is clearly exercised under s. 17 of the PLDPA, rather than concealed. Second, the Acts should not be treated as triggers for one another. The statutes have different purposes – the MHA test determines the legality of detention for the purpose of treatment, while the PLDPA determines the legality of the treatment itself; the approach to one should not pre-determine the approach to the other. Refusal under the PLDPA should not automatically lead to detention. If, however, the phrase ?immediate and serious harm…to other persons? in the MHA is being read – by psychiatrists or by the courts at the urging of foetus? own guardians ad litem – to include the unborn, the possibility of slippage between the Acts becomes starkly apparent. The government must address this interpretation.

I am not, for a moment, defending the PLDPA process. Under the PLDPA a suicidal woman may be assessed by 6 or more doctors before being granted an abortion. Even when applied properly the PLDPA assessment process may be gruelling. But it is equally indefensible to avoid the process altogether when a woman has requested it, and in so doing to strip her of all rights-protecting procedural safeguards.

(iii) Finally, we might ask when the Department of Health will provide full guidance on what doctors should do when a woman is refused access to an abortion. We know, for example, from the earlier case of Ms. Y, that such a woman may legally be subjected to treatment for the purposes of extending her pregnancy to viability, in order to facilitate later live delivery.  (Ms. Y was threatened with detention). Was it proposed to detain this child for that purpose? The law does not tell doctors how far they may go to preserve a pregnancy if it is determined that a pregnant person is not entitled to an abortion under the PLDPA. (Oddly, lack of ?legal certainty? in this respect has not become the same political football as has the same uncertainty around the right to access an abortion). The Department of Health Guidance reminds doctors that, under the Act, they must act ?as far as practicable? to preserve unborn life (including inducing labour or delivering early by C-section) without compromising the life (but not the other rights) of the pregnant woman.This girl was detained (apparently to her great shock) and in the process was prevented from travelling. Were appropriate safeguards in place?

This is a grey area, where doctors have been left largely free to exercise their own discretion, and where the state has failed to elaborate on any human-rights based limits. However, the limits are there. Today, for example, we got word of the UN Human Rights Committee?s decision in Whelan v Ireland. The principles are essentially those in Mellet v Ireland; that the Irish criminalisation of abortion, the attendant requirement to travel for non-life-saving abortions, and the associated restriction of abortion information, violate the human rights of women whose foetuses have been diagnosed with fatal foetal abnormality. Whelan is about a case outside the PLDPA regime, whereas this girl?s case was firmly within it. But Whelan, like Mellet, provides means to critique refusals under the PLDPA too. In particular, the defeated arguments advanced by the state in Whelan map how legal attitudes must be altered. First, in Whelan the state attempted to defend drastic and distressing infringements on women?s rights; prioritising unborn life over women?s autonomy. Whelan confirms that, under the ICCPR, the state does not have the power to arbitrarily restrict women?s rights in a broadly drawn attempt to protect unborn life.

Second, Whelan confirms the state does not fulfil its human rights obligations merely by clarifying the law of abortion on the face of statutes, without supporting women to navigate the structures governing that lawful abortion. ?Legal certainty?, for this government means words on the statute books, not the effective empowerment of women or the alleviation of their distress. This must change. It must change for abortions under the PLDPA as well as for abortions accessed in line with the right to travel.  

Third, women?s rights are violated through omission to adequately support them as much as by the culpable acts of individual state agents. At the same time, the state must restrict opportunities for individual obstructionist interpretations of the abortion laws, as discussed above. This must be done through the provision of proper guidance and training on the implementation of abortion legislation; whether the PLDPA or its inevitable successors.

Finally, it is no longer enough for the state to argue as it did in Whelan  (and A, B and C v. Ireland, D v. Ireland and Mellet)  that women can vindicate their rights (and extend the existing constitutional law) by bringing cases to the High Court. It is for the government to create genuinely workable law – this function cannot be delegated to women at the most vulnerable time of their lives.

By virtue of section 9(4) of the Refugee Act 1996, asylum seekers are absolutely prohibited from seeking or entering employment in Ireland. This provision has now been replaced by section 16(3)(b) of the International Protection Act 2015.  This provides that an asylum seeker,

shall??.

(b) not seek, enter or be in employment or engage for gain in any business, trade or profession…

Is this absolute prohibition on asylum seekers from entering, seeking or being in employment unconstitutional. The Irish High Court said no. The Irish Court of Appeal said no (see Maria Hennessy’s analysis of these decisions here).  The Irish Supreme Court has answered yes.

O’Donnell J (and the other six Supreme Court judges who agreed with this decision) have now decided to adjourn proceedings  for six months, after which an order will be made declaring the absolute prohibition of asylum seekers from exercising a right/freedom to work, unconstitutional. The Supreme Court agreed with the Court of Appeal ruling that no challenge existed to this prohibition under the ECHR Act 2003 (which I think is very problematic..) nor the European Union Charter of Fundamental Rights.

As O’Donnell J. noted, the core question that the Supreme Court had to decide could be broken into three core parts:

1. Whether there is an right to work under the Irish Constitution?

O’Donnell J. decided that yes, there is a qualified right to work under Art. 40.3 of the Irish Constitution. The reason I am saying qualified, is because, in light of earlier jurisprudence, O’Donnell J. has categorised this as a freedom to work, subject of course to other considerations (i.e. qualifications, experience to enable a person conduct the work they want to). The freedom to work goes to the “essence of human personality” (para. 13), even if (para. 15)

Much work is drudgery, often the subject of complaint rather than celebration, and most often an economic necessity as a means to live a chosen life rather than an end in itself.

O’Donnell noted that the constitutional recognition of what might be called a right or freedom to work does not entail obligations for provision of work, or even require the Government to adopt economic policies to enable full employment (para. 12).

However, the freedom to work recognises the “essential equality of human persons mandated by Article 40.1” of the Irish Constitution (para. 13).  Interestingly, and the first time ever to my knowledge, an Irish Court (and the Supreme Court no less) has relied directly on a general comment from the UN Committee on Economic, Social and Cultural Rights (para. 16) on the right to work:

The right to work is essential for realizing other human rights and forms an inseparable and inherent part of human dignity. Every individual has the right to be able to work, allowing him/her to live in dignity. The right to work contributes at the same time to the survival of the individual and to that of his/her family, and insofar as work is freely chosen or accepted, to his/her development and recognition within the community.

The Supreme Court stated that this description is “broadly consistent with that which was the background to the constitution” (para. 16). By exercising a freedom to work, a person can then ensure the protection of his/her other rights, within the family sphere, within the social sphere and within the societal sphere (para. 15). The right to work or more precisely the freedom to work, has been recognised by the Supreme Court as a fundamental part of human personality.

2. Whether  an asylum seeker can rely on this constitutional freedom to work?

The Supreme Court did note that a non- (EU) citizen has no automatic right to work in Ireland, this is subject to permission being granted. However, asylum seekers who are lawfully in the State for the duration of their protection claim, cannot be compared to other migrants who might be seeking a permission to work in Ireland. The right to work which goes to the “essence of human personality”, cannot be absolutely excluded for those seeking asylum. Work is fundamentally connected to ‘dignity and freedom’ (para. 15) and cannot be withheld from non-citizens.  ‘Significant distinctions’ can exist in the field of entry to employment between citizens and non-citizens and the Supreme Court stated the Oireachtas and “(where appropriate) [the] executive” judgment on the precise contours of the right to work for asylum seekers will in the main be respected by the courts.  The Supreme Court noted that the “pull factor” argument is a legitimate argument the Oireachtas may make reference to (para. 18). The Oireachtas may determine that by granting the right to work, it may make it more difficult to remove an asylum applicant who is not entitled to protection. In addition, the Oireachtas may have a power to limit the freedom to work for asylum seekers “to defined areas of the economy perhaps where there is a demonstrated need.” (para 18)

Therefore, while an asylum seeker may have the freedom to work, the Supreme Court decision provides significant scope for the Oireachtas to place limitations on this, and limitations that could not be placed on citizens. Its hard to equate the Supreme Court’s views on what may be permissible limitations, with the Supreme Court noting in para. 20 of its judgment the “damage to the individual’s self-worth and sense of themselves”.

3. What Next?

The Supreme Court decided that “in principle” they were prepared to hold (at para. 21):

where there is no temporal limit on the asylum process, then the absolute prohibition on seeking of employment contained in s.9(4) ( and re-enacted in s.16(3)(b) of the 2015 Act ) is contrary to the constitutional right to seek employment. However, since this situation arises because of the intersection of a number of statutory provisions, and could arguably be met by alteration of some one or other of them, and since that is first and foremost a matter for executive and legislative judgement, I would adjourn consideration of the order the Court should make for a period of six months and invite the parties to make submissions on the form of the order in the light of circumstances then obtaining.

The ball is now firmly in the court of the Oireachtas. However, the Oireachtas must be reminded (contact your TD here), that they are not starting from a blank slate.

First, the Irish High Court has already ruled that maladministration in rendering of a lawful decision on a protection claim may result in damages being awarded to an asylum seeker. Therefore, whatever course of action the Oireachtas takes, lets get this right. There has to be some focus on the ability of our quasi-judicial bodies who determine protection claims to do their work efficiently, but most importantly to be fair to asylum applicants.

Second, It would appear, that if Ireland became part of how European Union society deals with this question, then our Parliamentarians need to look no further than EU law for a solution to this constitutional protection of asylum seekers right to work. The Recast Reception Directive (which Ireland is not bound by), provides asylum seekers a right to work should generally be granted after 9 months where a first instance decision has not been rendered on a refugee/protection claim. The McMahon Working Group on the Protection Process and Directive Provision made a recommendation  (para 5.49) that once the International Protection Act 2015 was operating efficiently, that Ireland abide by this 9-month rule. Whatever the Oireachtas decide, this constitutional right of asylum seekers to have a freedom to enter employment must be effective, and not illusory (borrowing how the European Court of Human Rights insists on the realness of granted rights).

Image credit: Michael Foley

Lawyers for Choice has produced a draft bill that gives effect to the Citizens? Assembly?s recommendations for abortion law reform. The purpose of the Bill is to codify the Assembly?s proposals, and to show how simply and easily that can be done. The provisions reflect the choices of the Assembly members? and not those of Lawyers for Choice.

Regrettably, the Assembly?s deliberations on legislation were confined to grounds for accessing abortion only. Experience worldwide shows that, even where grounds are well-drafted, abortion can be difficult to access. The Oireachtas must pay attention to barriers to access such as obstructions outside of clinics, the circulation of misleading information on abortion, underfunding of services, and conscientious objection. Any final legislation must make provision for these matters.

In addition, we regret that the Assembly was unable to consider the decriminalisation of abortion, which is clearly required by international human rights law.

We welcome the Citizens Assembly?s recommendation that abortion be available on request up to 12 weeks, and on socio-economic and health grounds up to 22 weeks. However, we are concerned that the Assembly process did not always give members the opportunity to consider international best practice in the drafting of abortion legislation. To this end we note:

• The Assembly has recommended making abortion available predominantly only in exceptional cases. ?Exceptions-based? legislation can stigmatise abortion by treating it as being different to other forms of medical care. It imposes burdens on pregnant people to establish that their abortions are ?deserving?. It is also vulnerable to unduly conservative interpretation, which inhibits women?s access to services; for example, by distinguishing sharply between health and socio-economic grounds. We favour legislation which recognises and positively guarantees equal access to abortion care for all those who need it.
• We recommend that no ?rape ground? should be included in any legislation. In other jurisdictions, accessing abortion on grounds of rape requires women to ?prove? their rape to the satisfaction of medics, police or courts. Such requirements reinforce damaging myths about rape victims? credibility and lead to trauma and delay. Instead, the Oireachtas should ensure that other broader grounds (e.g. risk to health) can meet the needs of those pregnant through rape.
• We do not support a specific disability ground short of fatal foetal abnormality. Its inclusion is stigmatising. Again, care should be taken to ensure that other grounds are drafted appropriately to ensure that they can meet the needs of those unable to continue a pregnancy after a diagnosis of severe foetal anomaly. The state is reminded of its international obligations to provide appropriate social and economic support, information and medical care to those in this position.
• We regret that the Assembly?s recommendations include language from the case-law generated by the 8th Amendment e.g. ?unborn? and ?real and substantial risk? to life. These restrictive legal concepts have no place in Irish law once the Amendment is repealed or replaced and are unhelpful for medical practitioners.

The draft Bill can be accessed in full here.

We are pleased to welcome this guest post from Dr. Deirdre Duffy from the Liverpool-Ireland Abortion Corridor Project.

As the Citizens? Assembly turn to the ?when? of abortion access, many are highlighting that allowing first trimester abortion in specific cases is highly problematic. The question of access and first trimester care is complex so it is worth summarising the key problems with first trimester focused access.

Barriers to access

A central problem in the timely administration and delivery of high quality care is the existence of ?barriers to access?. These barriers can be structural, organisational, social, or personal and are usually a combination of a number of factors which prevent those who need care from getting it. By ?getting? here it is vital to recognise that patients are not passive – care is a dynamic process of requesting/approaching and being given care.

Importantly for Ireland, barriers to access are not just imposed from above but are embedded in cultures of care. So removing a barrier is more complex than simply funding an abortion clinic (for example) or making abortion legal as while the clinic may exist it may not have trained staff or have staff willing to perform abortions.  

Access and abortion care

In addition to questions about availability of trained professionals, financing of facilities, and proximity, abortion care has to factor in further barriers relating to abortion stigma and attitudes to abortion and women seeking abortion. As a result of abortion stigma, women may not approach care facilities for fear of repercussions. This barrier can be compounded by underlying norms and social factors both within and beyond caring institutions. If, say, a religious organisation which opposes abortion in all circumstances is placed in control of a hospital, a significant barrier to abortion care will inevitably result.

Abortion care access also needs to recognise the ?timings? of care-seeking and care-giving. Women may not know they are pregnant until well into the first trimester. Furthermore, health problems (foetal and maternal) become more apparent as pregnancy progresses. Acute care needs may only be detected in the second trimester or later and even then access may be limited by a lack of geographically proximate facilities.

What does this mean for a first trimester focused law?

The key problem with a first trimester law in Ireland is that barriers to first trimester abortion care are not impacted by liberalisation of abortion under 12 weeks gestation. Doran and Nancarrow?s systematic review (http://jfprhc.bmj.com/content/41/3/170.short?utm_source=rss&utm_medium=rss; paywall) on barriers and facilitators for abortion care in countries where abortion is legal and the Guttmacher Institute?s regular reviews of barriers to care in the United States highlight core barriers which may not be impacted by this sort of change. These are divided into patient and provider perspectives in the table below.

Synthesis of barriers to first trimester abortion care – from Doran and Nancarrow (2015)

What would this mean in practice?

If a first trimester liberalisation is instituted then the front-line of sexual and reproductive and maternity care in Ireland will need to be closely explored. As research I have already been involved in highlighted (see here: https://mcrmetropolis.uk/blog/what-happens-when-women-have-to-travel-abortion... ) communication between services in Ireland is not consistent. There are also significant issues relating to the cultures in hospitals – particularly if the Sisters of Charity are to be given ownership of the National Maternity Hospital, the key destination for acute maternal and foetal medicine – which will not be addressed by a legislative change.