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Dáil Éireann debate -
Tuesday, 15 May 1979

Vol. 314 No. 4

Health (Family Planning) Bill, 1978: Committee Stage (Resumed). Section 3.

Debate resumed on amendment No. 8:
In page 3, subsection (3), lines 23 to 27, to delete paragraph (b)
—(Deputy Browne).

The Minister may recall that I was dealing with the question of the likelihood of family planning clinics having to close down as a result of this legislation. Subsequently I find there has been an amendment in the name of the Minister which makes it appear likely that the family planning clinics will survive. The main point I am making is that they have provided a good service and that their ability to continue to provide that service depends on their right to sell contraceptives. This would help to finance their activities. That appears to be unlikely in the original Bill, but under the Minister's amendment it seems likely that they will be able to sell contraceptives, in which case they will be able to continue, assuming that they are operating within the regulations laid down by the Minister, which is as it should be. I shall leave the argument that I was making and ask the Minister if my interpretation of his amendment is correct.

Amendment No. 8 withdrawn?

Could I hear the Minister on the meaning of this amendment?

My amendment does not come up until section 4. I shall be speaking on the section in a moment.

Amendment, by leave, withdrawn.

Amendment No. 9 is out of order. Amendment No. 10, Deputy Browne.

I move amendment No. 10:

In page 3, subsection (4), line 31, after "practitioner" to add "or of trained family planning personnel".

The intention of this amendment is to seek to establish that in addition to general practitioners it will be possible for suitably trained and suitably informed advisers—nursing personnel, paramedical personnel—to provide the same service as is proposed under subsection (4): "Information, instruction, advice or consultation in relation to the use of contraceptives shall not be provided . . . except under the general direction and supervision of medical practitioners or of trained family planning personnel." A very good case could be made and has been made for suggesting that family planning clinics can be adequately catered for by individuals who are trained in these techniques. There is no great need for the restriction of information in relation to family planning to medical practitioners.

It is worth recalling that training in family planning methodology in the average undergraduate's training course is very limited indeed and that there are, according to the IMA, very few doctors capable of giving informed advice on family planning. It is generally accepted that the training in contraceptive procedure of people who want to get the service is very time consuming, especially in relation to the Minister's favoured method of natural family planning which is particularly tedious and time consuming, requiring a considerable amount of co-operation between the doctor and the persons looking for the information. Further, a general practitioner's job is very time consuming and he is involved in dozens of other activities in pursuance of his practice and unless he is particularly interested he will not have the time. In the context of the situation where trained personnel are so thin on the ground, will the Minister agree that in order to provide this service as quickly as possible he should allow for suitably trained personnel to carry out the service side by side with doctors or in place of doctors where doctors are not available?

This is a complicated problem because some doctors are opposed to the idea of family planning. In rural areas there would be no family planning service unless some paramedical professional persons decide to establish the service within the regulations established by the Minister. It is worth remembering that the Supreme Court laid stress on the ready availability of family planning to those who want to use it.

A number of conferences decided that broadly speaking a doctor is not a good person to administer this service, leaving aside individual weaknesses and other circumstances. A conference in Istanbul in June 1978 which involved a number of European countries agreed that the medical profession, especially obstetricians had been the greatest obstacle to the development of family planning services all over the world.

A Council of Europe report says that the provision of family planning services through medical channels only can limit accessibility. A number of surveys carried out in Ballinteer, County Dublin, concluded that because of the time consuming nature of family planning advice and services doctors were not the best people to give this kind of advice. Nurses can afford to keep up to date with the most recent developments in family planning, they are less expensively trained and are obviously completely competent to carry out the work and they have time to consult with social workers and so on. No case can be made for not extending the right to other individuals in the professions to carry out this service. In his letter to the IMA asking them to provide the service the Minister said that if a family doctor is not prepared to undertake this responsibility then clearly it will have to be laid on someone else. I imagine that in ordinary professional terms most of these services are predominantly staffed by personnel other than doctors so it is not an extravagant expectation that the Minister include this amendment to the Bill. In the same letter the Minister said that he had the power to arrange for education and training in family planning for doctors and other professional people. I cannot see why the Minister cannot look to this enormous reservoir of individuals and personnel. There are less than 20 doctors trained in family planning methods and counselling techniques. I cannot see why the Minister is so restrictive in this regard.

In reply to the Minister's letter the IMA said that doctors should not be the only route by which non-medical contraceptives should be supplied. The essence of the Minister's problem is to try to bring about as quickly as he can a family planning service which is widely available. The key to the Minister's problem is the question of personnel. In those circumstances it is a reasonable proposition that the Minister should include the words as suggested by me in my amendment.

I am not sure that Deputy Browne is on the right track. Section 3 (4) is intended to deal with the supervision of family planning clinics or places where family planning services are provided; it does not say that trained personnel cannot be fully involved in the provision of the service. In fact we would envisage that there would be, for instance, a nurse who is the obvious person that comes to mind.

The general principle enshrined in this Bill is that family planning services are a medical matter, that we are entrusting them to the medical profession and that in so far as they are provided anywhere it should be on the basis of a general practitioner dealing with them on a doctor-patient basis. If they are provided in some clinical setting they should be under the supervision of the medical practitioner. This is not to say that clinics must be manned totally by doctors—nobody would expect that—but that in any case where family planning services are provided it should be under the general direction, supervision and control of a medical practitioner.

That is all that is involved in subsection (4) as it stands. I do not think Deputy Browne's amendment is necessary. Of course these places will be able to avail of the services of trained personnel but it will be under the general supervision of a doctor. The whole principle of the Bill is that artificial contraceptives can be supplied only on the prescription or authorisation of a doctor. In so far as a family planning service would involve the advice and use of contraceptives, a prescription or authorisation of a doctor must be necessary.

Perhaps I have not been following Deputy Browne as he would wish but I find a certain confusion in his approach between the family planning function and the medical function. The question of family planning must be divorced from the question of the methods used to implement a family planning programme. This is very important. Throughout the community, in all camps and in all persuasions, it seems to be accepted that family planning is something to be considered in the modern world. Perhaps there is a good reason for this, namely the rapid increase in population in our time. So far as this Bill is concerned, family planning is a question of advice to people as to how to have a programme for family planning. General advice and what is set out in section 2 of the Bill do not require medical personnel as such. Some knowledge of human behaviour and human physiology would be necessary——

To what part of the section is the Deputy referring?

Very generally I am referring to section 2. Probably a knowledge of human psychology is just as important as a knowledge of human physiology. It is an unfortunate fact that when one comes to details one is immediately involved in medical matters which concern the health and well-being of the individuals concerned. One comes back to the medical profession in one way or another. I will leave for the moment the interesting suggestion of Deputy Browne regarding nurses who might work in certain areas.

Instead of talking around matters in general terms let us talk about them specifically. What are the methods by which one would implement a family planning programme using contraceptives? In an earlier amendment Deputy Browne spoke of voluntary tubal ligation or voluntary vasectomy. As I understand it, both of these operations are tying off, isolating certain organs. It is said that the operations are reversible but my information is that that must be qualified and that complications are not unknown. Whatever the pros and cons for these operations, in plain language they are surgical operations. Is it not wise that that should be restricted to the medical profession? I would shudder at the thought that anyone could come along and perform such operations. I am not for a moment suggesting this is what Deputy Browne had in mind and I hope he does not misunderstand me. History will testify to the necessity for reputable, well-established medical practitioner bodies. It is accepted that practitioners must be properly trained and skilled, must be properly registered and subject to certain professional controls. Quackery flourishes in all areas where there is likely to be remuneration and one of the things we must be careful about here is the commercialisation of sex. The operations I mentioned involve surgical attention and this area must be under the control of registered medical practitioners.

I will deal now with the area of drugs. The contraceptive drugs mainly in use are steroids. These chemical compounds seem historically to have been the subject of a certain amount of euphoria. They are the miracle drugs when discovered but, given a little time, the snags were found. I remember when cortisone was discovered in my young days and it was supposed to do everything. It is a very useful drug and can do much good, but the medical profession learned the hard way that cortisone is a steroid that must be carefully applied under the control of a medical practitioner who knows what he is doing. I do not know if there is any physiological significance in the fact that contraceptive drugs are chemically very closely related to cortisone—and cholestrol—which had for a while become the devil of popular medical literature and was said to be ruining our hearts.

I freely concede that the contraceptive pill is to some extent variable, depending on the mixture of steroids and their proportions. However, when it was first introduced it was said to be the answer to the contraceptive problem. Given a little time, contra indications were discovered, as in the case of cortisone. I will not inflict on the House a list of these indications because I am not a medical doctor. One has only to look in the Journal of Gynaecology where, because of American law, all these horrific warning and details must be given, just as in the case of tobacco. As a converted sinner, I share Deputy Browne's worry about tobacco.

The Deputy is the finest gem in my crown.

Deputy de Valera is in the best of company over there.

Do not send me back to hell.

I hope we are not going to debate tobacco on this Bill, together with all the other things which have been thrown in.

It is a fact that under American law when these things are advertised, particularly in medical journals, a list of these points must be published. These drugs have their uses in legitimate medicine but they are to a large extent regarded as belonging to the dangerous drugs category. They must be controlled as drugs, quite apart from the issue before us. On the other hand, they must be allowed their legitimate uses and I freely concede to Deputy Browne the right to construe the word "legitimate" in any way he likes. These drugs should be controlled and should be dispensed to human beings only through the medical profession essentially, with the proper relation to the pharmacist who is specifically trained. There is a dual tandem relationship between the two professions which has worked very well. These drugs should be dealt with by doctors and not by family planning personnel, no matter how well trained.

I now refer to intra-uterine devices, known as IUDs. Subject to whatever Deputy Browne may tell me—and I bow to his authority—I am informed that the introduction of these devices in situ does not require any particular medical skill. I am also informed that a number of cases require subsequent medical and surgical attention as a result of irritation and complications involving infection. These devices seem to be twisted pieces of metal which act by a scouring motion. The number of cases requiring medical attention is such as to warrant medical supervision at the beginning to determine, as in the case of drugs, whether the person concerned is a suitable subject. Too many cases come within the knowledge and competence of the medical profession because of the malfunction of these devices. Are these devices to be allowed to be used by people who are not fully trained and fully medically oriented? Surely they are dangerous in the same sense as drugs to an extent which warrants the same kind of control.

Having dealt with surgical methods, drugs methods and this mechanical method, I submit to Deputy Browne that in all reason it would be highly imprudent to allow anything falling into these categories to be used for medical or contraceptive purposes or for any other purpose without the control and supervision of a qualified medical practitioner in association, where necessary, with a qualified pharmacist. There is a very good reason for both these professions and here is a very clearly defined function for them.

I can think of only two other methods and I should be grateful to Deputy Browne if he would draw my attention to any I have missed. These other mechanical methods are the condom and the cap. I concede that these are two mechanical methods where Deputy Browne can make a case. Any fair-minded person, I think, would have to say that these appear to be free from the medical dangers to that ex-tent—whatever about the moral side which is another story. I simply ask Deputy Browne if that is what he is advocating, that these family planning people will be the dispensers of these rubber or plastic commodities. I think that disposes of the question. I fear when it comes to that one is dealing essentially with the question of public morality—I mean as far as we are concerned—with the question of the perverted use of these things for gain or propaganda purposes but I must concede that I cannot say in all honesty that they command the necessity of medical supervision that the other methods command.

I am back now to the main point. We must not confuse two things, family planning and the control of these other methods. Looking at everything, I think that the structure of this Bill is the best to suit our circumstances unless one is to take the view that free contraceptive devices should be available without restraint to everybody. If one takes that view I have no answer but from the point of view from which I personally would look at it I think the structure of this Bill is such as to strike a proper balance. I may correct that to say the best balance that can be struck at the moment in a very difficult situation. The proposed amendment in a very subtle way would strike at one of the principles of the Bill and for that reason I cannot agree with the mover.

It would possibly be helpful in the context of the amendment if the Minister would clarify whether the phrase "general direction and supervision of a registered medical practioner" would allow for the operation of clinics without the physical attendance of the registered medical practitioner at all times.

I approach this as a very urgent problem and one which it is very important from the point of view of our society should be dealt with as rapidly as possible. I do not want it to be mis-construed but it is something in the terms of a Third World country attempting to achieve an objective as rapidly as possible. I suppose there is some comparison with what I am suggesting here and the principle which is accepted in some countries of, say, assistants where a nurse is allowed to do a certain job which is ordinarily considered to be only permissible for a dentist to do. In New Zealand the marvellous advance in its dental services was achieved in this kind of way.

In reply to Deputy de Valera's interesting contribution, I would say that we may be at cross purposes—we do not know. In my opening remarks I asked if the Minister would tell us what kind of a service we shall get: he has not yet told us. I am trying to assume from his amendment No. 12 that we are going to get a service which broadly is the service at present made available in family planning clinics. But I have no right to say that because in fact the proposals I made for tubal ligation and vasectomy were thrown out by the House and therefore do not really arise in the Minister's proposals here. Even if they did, they are minor operations—certainly vasectomy is. I take Deputy de Valera's point that this is something which might be restricted to the medical profession but my suggestion is one which would mean that the people in charge of the service would for instance under section 3 (4) have to provide information, instruction, advice or consultation in relation to the use of contraceptives and so on. Really, none of these things, fittings of IUDs or giving medicines, pills, tubal ligation or vasectomy are to be made available under Deputy Haughey's Bill.

The Government's Bill.

I am sorry—the Government's Bill.

A nice distinction.

I take the point. We could argue it, could we not?

It is always the Government.

The whole Government; déja vu. If we held to the present Bill there is no reason why my amendment could not be accepted. Deputy de Valera went into some interesting arguments into which I do not propose to pursue him on this section because I think they will come up later on and I shall be glad to deal with them then. I was interested in his—I wonder what position it will lead him to take up later on—remarks about the doctor deciding about having the right to write prescriptions. He appeared to differentiate between abstention and what he calls natural family planning and the various pills, ligation, sterilisation and the IUD. He makes the case which is frequently made about that, its abortifacient and carcinogenic possibilities, which it certainly has, I understand. Incidentally, I do not want to claim knowledge I have not got. I am a general practitioner at best and a specialist in quite a different training to the one involved here. I do not wish to appear to be an authority on the subject; I am not. He then came to two points, the question of the cap and the condom. He seemed to think it would be permissible to allow these two to be provided by lay people, effectively, nurses or paramedical personnel. That is a very interesting concession because it is the one we will be trying to establish in a later amendment.

I said I did not think they needed medical control.

The point I am trying to make to the Minister is that he is certainly right in relation to condoms, although not necessarily—there is a fairly good case for a certain amount of education in respect of the use of the condom, oddly enough—but in relation to the cap, it is necessary that there should be a certain amount of instruction because there are various sizes, the question of how to fit them, and the use of spermacides with them. I do not think there would be any difference between us on those two, conceding the other ones, my case being that under this Bill it is simply an information service which is being provided by the Government. I will be very interested to see whether Deputy de Valera will take up that position in relation to the condom and the cap at a later stage.

In my attitude to family planning I am not claiming any loyalty to any method. I am attempting to establish a position for the Minister in a pluralist society who is asked to take on the responsibility of providing an efficient, easily available and safe service, with a multiple choice because of the various different needs of the persons presenting themselves. I am trying to establish the point that the Minister's own attitudes, his ethical attitude, his moral standard of values, and his religious beliefs are completely irrelevant. He has a responsibility to provide the best possible service. Despite remarks by Deputy de Valera about the kind of people we are, and about the social and ethical attitudes we have, we are a pluralist society. There are people who do not agree with the natural form of family planning and who are perfectly happy with various other forms. I have not yet said whether I agree or disagree with sterilisation. It is not important. It does not matter. A lady may be a Jewish lady, she may be Church of Ireland, Presbyterian, Roman Catholic, atheist, agonstic, or Muslim, or any kind of person living in our society. She will ask for the most efficient service and my answer will be: "This is the most efficient service", and privately I might not agree with it but the decision must be hers. I wish we could establish that point.

That is not at issue here.

I will not dwell on it. Reference is made to "natural" and "unnatural" methods of family planning. Both are wrong, but it is of interest that we never got from the Minister an explanation of the enigmatic "secure" and "provide" in section 2. We did not get an explanation of what he meant by the use of those two different words. Section 3 (2) provides:

A person other than a health board may make available a family planning service for the provision of information, instruction, advice and consultation in relation to methods of family planning that do not involve the use of contraceptives.

There is no question of regulations or no question of medical supervision there. Presumably this service can be carried out by nursing personnel and paramedical personnel. Why? Some of the methods used in, let us call it, unnatural family planning without a shadow of doubt do not need skilled medical advice for their use. Why is there this distinction which runs right through the Bill making one kind of service relatively inaccessible and another freely available with all the force, power and wealth of the Minister behind it in order to promote it? These are questions which will arise on other sections and I should like to hear what the Minister feels about them.

I really have not a great deal to add. I do not think Deputy Browne has established a case for his amendment. We are talking here about clinics which provide a family planning service involving the use of artificial contraceptives. The principles on which this legislation is based are quite clear. It is a fundamental principle that a family planning service must be firmly anchored to the medical profession. Rightly or wrongly, that is my approach to the Bill. This is more appropriate to a family doctor context than anything else. That is my approach, and that is what is involved in subsection (4) which provides that if there is to be a clinic of any sort it has to be under the general direction and supervision of a medical practitioner.

That is all it says. It does not say everyone in the clinic has to be a medical practitioner. Many people will be employed in these clinics who will not necessarily be fully qualified medical people. In so far as any clinic is set up to give advice and information about family planning matters, I want to ensure that it will be under medical supervision. I do not want family planning clinics springing up all over the place under people who are not qualified to run such institutions. If we were to adopt Deputy Browne's amendment we would be leaving it open to anybody to establish a clinic of this sort.

His amendment asks for trained family planning personnel. What does that mean? A medical practitioner has a clearly identifiable standard of qualification. Whether you agree with it or not, the principle of the Bill is that family planning services are being placed under the general jurisdiction, control, supervision and direction of the medical profession. That is my approach. That is how I think this matter should be tackled. I would not be prepared be consider the establishment of family planning clinics other than under the direction and supervision of a medical man or woman.

Deputy Boland asked me to elaborate on what I mean by general direction and supervision. In this subsection those words would have their normal meaning. Time and again in the health services we talk about institutions, or bodies, or agencies, or clinics, being "under the general direction and supervision". It does not necessarily mean that the medical practitioner will have to be there 24 hours a day. How he or she manages the general direction of the clinic is a matter for her or him, but the meaning is quite clear. The manner in which the place is conducted, the activities carried on, the type of instruction, advice and consultation provided will be prescribed by the medical practitioner in charge.

There is the subsidiary argument that in so far as family planning services would involve the use of artificial contraceptives, the prescription of a general medical practitioner will be necessary. It is impossible to think of the clinics without a GP being involved in their running and supervision. In so far as there will be family planning clinics, I regard them as very important places. I will ensure that they will be licensed first of all, and they must be up to a certain standard, and the way in which we will ensure that they will be up to a certain standard is by putting them under the general supervision and direction of a fully qualified medical practitioner.

I should like here to make a point in reply to various criticisms of this legislation inside and outside the House, particularly by those prolific writers of letters to the newspapers. I often wonder do they have anything else to do apart from writing letters to the newspapers. This Bill places family planning services in the context of family medicine. If I had brought in a Bill which did not do that, can Deputies imagine the volume of criticism there would be? The cry then would be that family planning should be a medical matter, that the persons who should have control of family planning are the doctors, not policemen. If we had left this legislation in the Department of Justice, for instance, can Deputies imagine the outcry: "This is a medical matter and nobody in the country is better qualified to look after family planning matters than the family doctors". That would be the outcry all over the place. But because I have done that, there is another outcry. Apparently it is a detrimental thing to ask the best qualified people, trained people with the most wisdom and experience in these matters, to take control and direction of this service.

Sometimes I despair of trying to achieve some sort of sensible consensus, but out of all the arguments, and allowing for all the disadvantages involved in what I am proposing, I suggest that it is the best system, the sensible system. We are asking the right people to take charge, the family doctors. It is for that reason that subsection (4) is in the Bill and it is for that reason that I do not want to accept Deputy Browne's amendment. I do not want to have the family planning clinics under the general direction of anybody except fully qualified medical practitioners.

The Chair appeals to Deputies to keep strictly to the amendment. If we are going to debate the whole Bill on every amendment there will never be an end to it.

I will keep strictly to the Minister's last argument. He made the point, which I share, that family planning clinics must be kept up to a certain standard by fully qualified medical practitioners. I accept that, but the Minister is proposing that a family planning service will be set up throughout the country, a comprehensive service providing consultation and advice in relation to methods of family planning that do not involve the use of contraceptives. Is that not the position? There is to be a widespread family planning service of that kind without any medical supervision and, as far as I know, without any specific regulations laid down by the Minister. Why is there this dual provision in relation to two aspects of family planning? I take the position that there should be all forms of family planning available and that individuals should be able to make their choice, and that all the services should be of the highest standards laid down by the Minister and the Department. I fail to see why the Minister did not make any attempt to clarify that point in the discussion on the Bill so far.

The Minister has taken up the position that there must be a prescription. I will not deal with that now because I hope we will be dealing with it on a later amendment. He said a prescription will be necessary. I accept that a prescription will be necessary for certain drugs and medicines, as mentioned by Deputy de Valera. However, Deputy de Valera made a distinction between two kinds of contraception. On one matter I would go along with him. Then there is the question of the diaphragm and the condom. He did not think a medical certificate would be needed in relation to these—I hope I am not misconstruing him. He did not seem to think that these had anything like the seriousness of the other three or four that he mentioned—I am sure he knew what he was talking about. Does the Minister take up that position, because it is a most important one?

I want to be clear. There must be prescriptions for all forms of artificial contraception. Agree or disagree with the Bill, that is what is in it.

That is interesting because I do not think anybody could give Deputy de Valera the label of a way out radical——

A red roaring liberal.

I do not think one can say that about him, but he took that position in his contribution. Of course there must be a distinction because this restriction of a medical prescription is the most absurd feature of a Bill which is so full of absurdity.

I was talking from a purely physical point of view. In the psychological area I am not so sure whether the others are included.

Will the Minister talk about the proposal I have put about fitting and supplying, because it is fundamental? Will the clinics fit and supply? If they are to do so, obviously they will be a completely different type of clinic from those envisaged in the Bill. Rightly or wrongly, I believe that is what the Minister has in mind. If that is so, it stops me as far as my amendment is concerned. We seem to be discussing a different kind of clinic altogether.

Is amendment No. 10 being withdrawn?

Is the Minister not going to reply?

I shall deal with the whole question of clinics later. At this stage I am only concerned with the type of person who will operate the clinic. I am firmly enunciating the principle—and I will not depart from it unless the House defeats me—that any family planning clinic must be under the direction and control of a medical person.

We can take it from that that a clinic could operate without the physical presence of a medical practitioner as long as a medical practitioner accepted the responsibility and was acceptable to the Minister for the purpose of issuing a licence. His physical presence at all times would not be required.

In the normal course of events I would think so.

Amendment, by leave, withdrawn.

I move amendment No. 11:

In page 3, line 32 to 36, to delete subsection (5).

Section 3 (5) reads:

A health board or other person making available a family planning service under subsection (1) or (3), as the case may be, of this section shall ensure that the service includes information, instruction, advice and consultation in relation to methods of family planning that do not involve the use of contraceptives.

I would take the amendment in the context of subsection (6) which reads ". . . this subsection shall not be construed as restricting the discretion of a registered medical practitioner in his clinical relations with a patient." The Minister appears to be attempting to direct the medical profession as to what they will do in the provision of a family planning service. There appears to be a conflict. Under subsection(5) the Minister is attempting to direct the medical practitioner to provide the kind of service that he does not agree with.

If that were involved, Deputy Browne would be right in removing the subsection. The Deputy will note that the subsection refers to a health board or other person making available a family planning service. The section is designed to ensure that in so far as a family planning service is provided there must also be provided access to information and advice on natural family planning methods. In other words, to ensure that the patient will have access to natural family planning advice as well as to advice on other methods if they so wish.

I accept the Minister's explanation but it still brings in the point I made that the emphasis on the natural family planning method to the exclusion of other methods referred to by Deputy de Valera, which were not referred to by the Minister, is a strange preoccupation with natural family planning. Must a doctor who does not agree with it and who thinks that it would be wrong for his patient provide advice on this method, even if his patient comes to him for a IUD or the pill and so on? Instead of the Minister telling the general practitioner to do something, the Minister is saying that the board must tell him to do something, that is, to provide this service within the services provided by the health board. Is that the Minister's intention?

I have no such intention. The principle is firmly enshrined in the Bill that nothing interferes with a doctor's clinical relationship with his patient. The doctor is free to give his patient whatever advice he or she wishes. Furthermore, the patient is entitled to seek any sort of advice or service. The Bill was designed to make artificial contraceptives available to those who require them for bona fide family planning purposes, so there is no question of interfering with the choice of the individual. This section says—and I wish Deputy Browne would accept it on its face value—that in so far as there is an agency or a health board providing a family planning service in a clinic, there shall be available in that clinic advice and information on natural family planning methods as well as other methods.

I assume that Deputy Browne's reason for entering the amendment is his objection to the obligation being placed on clinics to give information about natural methods of family planning whereas clinics giving information on natural methods per se are not obliged to give information on artificial methods.

The Minister said that there will be a service which does not involve the use of contraceptives. The wording he uses in the subsection is ". . . this section shall ensure that the service includes information, instruction, advice and consultation in relation to methods of family planning that do not involve the use of contraceptives." The use of the word "shall" appears to be mandatory. It appears that this is something that must be provided in a service which may be more interested in the more efficient methods.

It is my intention to be mandatory. A family planning service must provide information on natural family planning methods.

Why is it the Minister's intention to be mandatory in view of the long argument we have had as to the inefficiency of it?

I do not agree with that point. The Deputy suggests that it is inefficient. I have just quoted some figures which say that natural family planning methods can be 98.5 per cent efficient. There is a large volume of medical opinion which favours natural family planning methods and a large number of people will avail only of such methods no matter what Deputy Dr. Browne or anybody else may think. That is their outlook and approach to life. I respect that. I am making it mandatory on any family planning clinic providing a family planning service to make available, side by side with any other method, information and advice on natural family planning.

Amendment, by leave, withdrawn.

I move amendment No. 12:

In page 3, subsection (6), line 38 to 40, to delete all words from and including "but" in line 38 to the end of the subsection.

This section, as I said in my contribution on subsection (5), is in conflict with itself. What the Minister is saying is that:

(6) A family planning service shall not be made available except in accordance with the provisions of this section but this subsection shall not be construed as restricting the discretion of a registered medical practitioner in his clinical relations with a patient.

A doctor who finds himself in a family planning clinic will have to make available a service or give advice on a service with which he is not in clinical agreement. There seems to be a contradiction in this subsection. The section would be strengthened by leaving out this homily to the doctor that he need not do anything which is in conflict with his own clinical judgement in respect of any case. Under subsection (5) it is mandatory on him to give advice that he may not agree with.

I do not accept that interpretation of subsection (5). Deputy Browne is just being impish in suggesting this should be deleted. It would be most unwise to delete this saver. It is a fundamental safeguard of considerable importance, that a medical practitioner shall not be in any way interfered with in his clinical relations with his patient.

There are medical practitioners who conscientiously could not advise natural family planning. The necessity for the safety of the method, its simplicity and efficiency and also the multiple choices I have mentioned are pre-conditions involved in giving a woman advice which may be a matter of life and death to her. In the McGee case there was no question of natural family planning.

That is what I am protecting here.

In the McGee case the lady was not allowed to plan her family. A question of death was involved. There had already been a mistake in relation to one of the methods used. She could not afford another mistake. The question involved in contraception is efficiency, simplicity and safety. In the McGee case tubal ligation would probably be the correct solution. If a doctor is faced with a person coming to him for advice on what he thinks is the most efficient method and if he is working in a clinic which says he must tell her about this other form of family planning which is not as efficient, what is his position? He is convinced there is a simple solution to her problem, for example that it is tubal ligation, the pill or IUD, use of the condom by her husband or a cap by herself or spermacides. What is the purpose of asking a man to provide a service he does not agree with, on the one hand, and, on the other, telling him that nothing in the Bill will impose on him a commitment to give advice that he does not believe in?

The Deputy is arguing for retention of the words his amendment proposes to delete. Nothing in my approach to the Bill, and furthest from my mind, is any suggestion that a doctor should have to give advice in which he does not believe. Deputy Browne stresses one side of that. He asks why a doctor who does not believe in natural family planning methods should have to give advice on them. The answer to that is that he will not have to. The other side of the coin is that there are many medical practitioners who will not advise on family planning methods involving artificial contraception methods. I know a number of such doctors. They also are entitled to their professional freedom not to advise artificial contraceptives just as another doctor is equally free not to advise natural family planning methods if that is his belief. There is no compulsion in the legislation to compel a medical practitioner to advice anything he does not believe in and that cuts both ways.

I am not aware of any medical practitioners who have total animosity to natural family planning as Dr. Browne says some medical practitioners have. However, there may be some and, if there are, these words protect them fully from advising in favour of such methods. Equally, and far more common, would be the case of medical practitioners who do not wish to advise their patients to use artificial contraceptives. They are also protected by these words. Everything points to the retention of the words in the subsection.

Does the Minister not see a contradiction? I tried to take subsections (5) and (6) together because the contradiction appears to arise from the mandatory use of the words:

shall ensure that the service includes information, instruction, advice and consultation in relation to methods of family planning that do not involve the use of contraceptives.

If the doctor is the only doctor working in a clinic he must give advice that he may not believe in.

He must ensure that advice is available. Somebody else may give the advice. No medical practitioner need give advice which he does not subscribe to himself. We dealt with subsection (5) and are now on subsection (6) which is a saver for the professional integrity of medical people.

The point made by the Minister is an interesting one because it is in complete conflict with the whole tenor of the Bill. The Minister now says that it is possible to run a family planning clinic in which somebody will be giving advice on family planning other than a medical practitioner. Although that other person will be an authority he will presumably not be a doctor.

There could be two doctors.

Is this what the Minister is going to do in order to see that this dual service or multiplicity of services is provided? Is there going to be more than one doctor?

In any piece of legislation all sorts of artificial, hypothetical absurdities can be created; it does not take a very clever person to do that. The essential thing here is that a clinic providing family planning services will be under the general supervision and direction of a particular general practitioner. It will be his responsibility to see to it that people coming there have access to advice and information about natural family planning methods whether or not he believes in them. He does not clinically have to give that advice but if he is in charge of the clinic it is his function to make sure it is provided by some other person, another doctor or a trained person. It is as simple as that.

We have already dealt with this and we are going back on it quite a bit.

I want to make just one point. Is the Minister not now accepting an important basic point? The Minister is becoming a little bit anxious and a little impatient of the fact that we are examining this Bill seriously. On the one hand he gets angry with the main Opposition parties because they did not examine the Bill and he is now getting angry with me because I am attempting to examine it seriously to the best of my ability. The Bill is so full of contradictions and so capable of many interpretations. I am simply giving some of them here. The final point which concerns us first is that a Minister's undertakings are worthless in a court of law. What is going to be important is, for instance, a medical practitioner who is appointed to one of these clinics who happens to be a Jew, a Presbyterian, a member of the Church of Ireland or some other religion or simply a doctor who has none of these religions or a doctor who happens to believe that there is a particular planning service which should be made available for a particular lady in her situation; it is mandatory on him in this clinic to give advice which he knows is worthless to the lady in the circumstances, or to appoint somebody else to give her advice which he knows is worthless. How could he be considered as being in charge of the clinic if he makes arrangements for giving advice which he knows is worthless?

All I want to say at this stage to all the people present is that we are once again going back to amendment No. 11 on section 5. It does not arise at all. We are dealing with amendment 12 to subsection (6).

Deputy Browne is missing the point. A family planning service within the meaning of subsection (6) can be a health board or any group that is authorised by the Bill to give it. The doctor comes in in relation to the use of contraceptives and if he looks at subsection (4) he will see that. It is in relation to the use of contraceptives that the medical profession is particularly involved. Subsection (6) is as the Minister explained. I do not wish to delay the House by going into it. Subsection (6) is the saver for the medical profession here: it does not compel them to give advice on anything else. The fact is that the supervision of the registered medical practitioner is required in the restrictive case where there is advice or consultation in relation to the use of contraceptives and nothing else. It is not general family planning at all and I think that disposes of Deputy Browne's point.

Amendment, by leave, withdrawn.

I move amendment No. 13:

In page 3, subsection (6), line 40, after "patient" to insert "or of a pharmaceutical chemist in relation to the provision of information, instruction or advice to a person to whom he is selling contraceptives in accordance with this Act."

This amendment has been put down at the suggestion of the pharmacy profession who are anxious to ensure that the terms of the Bill would not prevent them giving advice across the counter to persons to whom they are selling contraceptives in pursuance of a prescription or authorisation. I am not sure that they would have been prevented anyway as the Bill is framed but just to make sure that they will not be so prevented from giving that type of friendly advice for which they are invaluable in the community I am putting these words in the amendment.

We have had a new dimension introduced in the Bill now. We have discovered that pharmacists are being invited to give friendly advice in relation to these matters to their customers. On Second Stage I asked the Minister whether he was satisfied that the provisions of the Consumer Information Act would not inhibit doctors or indeed others in relation to their dealings with people who went to them and who were not going to get advice or information in the normal medical way. I wondered whether these two savers, the one in the original Bill under subsection (6) which Dr. Browne has been discussing and this amendment would have the effect of being savers in relation to groups or professions in so far as the Consumer Information Act is concerned.

I would like to say this about it. This is tied to the fact that pharmacists can only be involved where there is a prescription. It is exactly the same as when a doctor gives a prescription for drugs which the pharmacist provides; he will very often tell the patient he should not take something else with the particular drug, or drink too much or drive a car while taking it. That is the type of advice that the Minister means and let us remember that there must be a prescription and the pharmacists are not free.

That is not the point at all. Deputy de Valera has not grasped the fact. The doctor will not be empowered to issue a prescription or an authorisation; this is a new piece of doctor—pharmacist or doctor—patient jargon and there is no such authorisation mentioned in the various Acts regulating the medical profession or the pharmacists, but the pharmacists will now have to act on an authorisation from the doctor who will now be required to write an authorisation as opposed to a prescription. But the Consumer Information Act of 1978 states at section 6:

If a person, in the course or for the purposes of a trade, business or profession—

(a) makes a statement which he knows to be false, or

(b) recklessly makes a statement which is false——

or a statement recklessly made which turned out to be false in relation to any service or convenience,

——shall be guilty of an offence.

It goes on in subsection (3):

In relation to any services consisting of or including the application of any treatment or process. . . the matters detailed in subsection (1) shall be taken to include the effect of the treatment, process or repair.

The point was made on Second Stage that another similar provision in relation to a profession was not included in that similar section because of the difficulty for professions in giving advice which might turn out to have the effect or to have a contrary effect or to have effects which were not in the interests of the person to whom the advice was given. I asked the Minister to clarify at that stage whether or not doctors would be affected by the provisions of the Consumer Information Act. I did not deal with pharmacists at the time but the point arises now because of the Minister's amendment. Would the Minister's amendment be a saver that would exclude them from having an aggrieved person seeking to take action against them under this Consumer Information Act? That is the reason I ask the Minister this question and I hope he will deal with it.

This amendment I am proposing has nothing to do with the Consumer Information Act. As it was suggested that the restrictions and the provisions of the family planning service might possibly prevent a pharmacist from dealing with one of his clients who applied for contraceptives giving the sort of across-the-counter advice which he normally gives about the medicines he supplies, this amendment is to make sure that he will not be so prevented. That is all that is behind it.

Amendment agreed to.

Amendment No. 14 has been ruled out of order.

Question proposed: "That section 3, as amended, stand part of the Bill."

There are a number of objections to this section, some of which have been outlined by Deputy Browne in the course of the discussion on the amendment. I do not propose to delay the House unnecessarily by reiterating those reservations. It seems strange that all clinics will be obliged to provide information about natural family planning methods but clinics which apparently are exclusively to deal in natural family planning methods will not be in a position to make available advice or information on methods other than natural family planning methods. I hope the Minister will clarify, in relation to this section, whether the advice and information which he proposes will be disseminated through health board family planning clinics will also contain information relating to non-natural family planning methods. Although that is presumed in the Bill, I do not see it spelled out clearly.

In subsection (1) of this section the Minister will make regulations to see that health boards provide family planning services. In relation to those regulations a point which was raised on section 2 arises also on this section, how it is envisaged family planning clinics might be set up through the health boards. Can the Minister indicate if there will be an even provision of services in different parts of the country, especially in the rural parts where I suggest the services might be more urgently needed than in some of the urban areas where may people have already made their own arrangements? I believe that in many rural parts of the country there are many poor people who are in urgent need of advice in relation to family planning matters generally and who find it difficult to avail of such advice and services even under the present set-up because most of those centres are in large urban areas.

I hope the Minister will be able to clarify his intention in relation to the regulations which he will be obliged to make under subsection (1). It would really be too bad, with all the other deficiencies in the Bill, if we were to discover in five years that some of the health boards were not operating a family planning service because they had not sufficient trained medical and other personnel, that they had no premises or had difficulty in their budgets. It is important to have a procedure laid down under which the services are available on a nationwide basis within a reasonable length of time.

In regard to the general trend of what Deputy Boland is suggesting I believe I have taken care of it in section 2(1) where there is an obligation on the Minister to secure the orderly organisation of family planning services throughout the country. That would be my approach. We rely, first of all, on the general practitioner to supply a family planning service but should it appear that it is necessary to supplement that, then the health boards will be able to establish clinics where the need for them can be demonstrated. These clinics will provide a full-scale family planning service in the sense that they will give information, advice and so on about artificial contraceptives as well as natural family planning methods. It is my obligation to ensure that family planning services will be provided on an equally acceptable basis to all families throughout the country.

I am glad to hear that. Presumably the Minister intends including in the regulation an obligation on the health boards to ensure that the family planning services deal with all methods of family planning. The Minister will appreciate that the type of service is not spelled out specifically in section 3.

It is implicit in it but I accept the Deputy's point.

It is implicit in it, but if it were not contained in the regulations it might possibly be used afterwards by some of the health boards to provide a restrictive form of service. There are two other matters of major concern. The first is in relation to the scale of activities which the non-health board clinics could provide. The section as it stands is very objectionable but there is a ministerial amendment in relation to 4 (1) (b) (i) which we may assume will be passed. If that amendment is passed it will radically alter the position in relation to the clinics as set out in section 3 (3). It makes it rather difficult to dicuss this section because the amendment in question is an amendment to a subsection of a later section.

We must dispose of section 3 first.

If I realised it in time I would have suggested that the Minister's amendment to section 4 might have been discussed with section 3.

We can discuss the matter fully on section 4.

If that amendment is passed the effect will be that the clinics will be allowed through a rather circuitous route to make contraceptives available.

We cannot discuss that amendment until we meet it.

Section 3 as it stands will not allow any of the family planning clinics, no matter how satisfied the Minister is about their operation or about the responsible attitude they might adopt, to actually provide contraceptives. They may provide information, advice, instruction or consultation in relation to family planning methods but they will not be allowed per se to actually provide methods of contraception in the clinics. People who go to one of those clinics will only be entitled to get advice. They will then have to leave the clinic to get a prescription from their family doctor, if there is not a doctor in attendance in the clinic. They will then go to a chemist to have the prescription dispensed or the authorisation fulfilled as the case may be. It would appear from the later amendment, if it is accepted, that in a roundabout way the clinic will be allowed to distribute contraceptives through the involvement of a chemist or through the clinics acting as agents or servants of chemists. The House is being invited to speak about this section in a vacuum. I assume the amendment will be accepted and we can discuss the matter more fully at that stage. The amendment would improve many of the unpalatable aspects of section 3.

The other point under section 3 concerns me greatly. It is becoming increasingly obvious that there is a need for trained personnel in the field of providing information and advice on family planning methods generally. Everybody, the Minister included, has accepted that. It has become even more obvious that there is a need for a high level of training and skill on the part of the people dispensing information about methods of natural family planning. The imparting of information about natural family planning methods, especially in connection with the Billings method, must be of the highest standard, because there can be a radical difference in the success of the method.

The Minister should have been at pains to include in this section a requirement that where natural family planning advice was being disseminated, the people giving that advice were trained to a certain degree, presumably as specified in regulations to be made by the Minister. That is not included in section 3. Even at this stage I invite the Minister to consider amending section 3 on Report Stage by the inclusion of that requirement.

I will consider that.

We are going to oblige the health boards, the natural family planning clinics and other clinics—who are more interested in other methods of family planning—to provide information and advice on natural family planning methods. Even in the limited way in which advice is disseminated at present, all those involved accept that there is a need for a high degree of skill. I would have thought it very necessary that the obligation to have trained personnel disseminating that information should be included in the Bill and this is the appropriate section to do it. I invite the Minister to comment on that.

I will have a look at it between now and Report Stage.

Is the Minister standing by his statement for providing family planning services? He is on record as saying that the contraceptives prescribed would have to be paid for—appliances, condoms and so on at the health clinics. I would like him to clarify this point and I suspect this is the right section on which to do it. What is his attitude to the card-holding person who goes to a family planning clinic for advice and is advised that he or she needs a particular form of contraceptive? The Minister knows that at present a considerable number of women attend these family planning clinics, or their doctors, and can be provided with cycle regulators—I understand 38,000 women use the pill on prescription every month and this is a considerable number.

My attitude would be in the light of the many social problems which we have failed to solve, such as unemployment, bad housing, lack of recreational facilities, the terrible prospects of jobs for youngsters and so on. The urgency of these problems make it imperative that the service should be free to everybody who wants to use it. However, I suspect that is something that does not appeal to the Minister. There is a sector of the population, the lower income group, people who are eligible for free services and free facilities under those services and, as far as I can see, they will have to pay for these different kinds of contraceptive devices—from the pill to the condom. This is a retrograde step because under the Acts as they are at the moment the Minister can provide for family planning services, in certain circumstances, in the lower income group and they do not have to pay. Whether that is so or not, it is a fact that many of these 38,000 women are being prescribed the pill as cycle regulators and are able to get it free of charge.

People with medical cards are predominantly the most needy, the people we should try to help before all others, because they are the unfortunate ladies who frequently live in overcrowded conditions, have difficult conditions in unemployment and employment, have money difficulties, already have too many children and, as I said on Second Stage in my own practice in working class areas, spend most of their lives in fear of the next pregnancy. They are the kind of people who should be facilitated in every way possible. Obviously the motivating force as far as I am concerned, in advocating contraception is, first, the protection of their health—this is agreed by practically everybody: the United Nations, the World Health Organisation and many other institutions and authorities in the world and, secondly, the availability of family planning or easy access at any rate to family planning and obviously easy access. If you are in the lower income group it is quite possible that the cost of contraceptives, the IUD's——

Deputy, we have discussed this rather extensively on section 2.

I am attempting to point out to the Minister that the statement that contraceptives prescribed would have to be paid for would impose a very great hardship on a very important sector of society: the lower income group for whom the general principle has been accepted in our legislation under all Governments that they must be assisted by the rest of the community. They themselves pay for their health contribution. The employer pays to some extent. Therefore, the Minister insists that it is desirable that this service is provided by medical practitioners because it is a medical need. Then why is it differentiated from other kinds of services that are provided as a result of a patient going to a doctor and getting a prescription for some kind of kidney complaint, liver complaint, stomach complaint or the different kinds of ills that affect the human body? Why should we restrict the free service to this kind of patient? Why should she be able to come along and get her prescription to get any kind of drug or appliance from the most innocuous to the most dangerous if it is in the opinion of the doctor medically desirable that she should have them? In this situation, as was pointed out on a number of occasions, it is a matter of life or death for her that she gets some form of contraceptive protection, that in certain circumstances there is a hazard to her life, it is something which, if she does not have easy access to it, can subject her family to distress and disruption. As we know well from dealing with this kind of person, it can endanger the security and happiness of her marriage.

These three conditions are, of course, the three points made in the McGee case by the Supreme Court in attempting to establish—as was established—the right of ready accessibility to family planning contraceptive methods. There is no doubt that for certain income groups this is no problem. We should not impose on the lower income group the impediment of having to pay for this service which is sometimes quite costly.

Perhaps the Minister will tell us what his attitude is? Is any kind of service provided by these family planning clinics? May such a person continue to have access to the pill freely? May she have access to IUDs which would be quite expensive between fitting and supplying, to diaphraghms, spermacides and condoms? Does she have any right at all to these services free?

I am permitting the Deputy to make that point now but I doubt whether it is relevant to the section.

The making of the facilities accessible to her would seem to be one of the primary functions of this legislation. What is the Minister's attitude? I ask him in respect of, say, the 38,000 women who are at present on the pill and many of them getting it as a cycle regulator.

This Bill will make no change in the situation. This Bill deals with the availability of artificial contraceptives for family planning purposes. It has nothing to do with the general medical service. What may or may not be provided by the GMS is an entirely different matter and not relevant to this section.

The Minister is on the record as saying that contraceptives prescribed would have to be paid for. Is this statement correct or was he misquoted?

I am prepared to stay here all year if necessary but it is a waste of parliamentary time. We are going over the same ground over and over again. I have already explained on a number of occasions what exactly the position is. If a medical practitioner prescribes any form of medicine or drugs for a patient for medical reasons and that patient is a medical card holder the GMS provisions apply. In so far as a medical card holder goes to his or her GP for advice, consultation and information on family planning, in so far as the visit to the GP is concerned that visit comes within the provisions of the GMS. In so far as the person requires artificial contraceptives that person has to go to a pharmacist to procure those artificial contraceptives on the basis of a prescription or authorisation and to pay for them.

There appears to be a conflict in what the Minister is saying. He must not become impatient. On a number of occasions Deputy O'Connell and I during Question Time tried to get a simple statement on this from the Minister and we failed to do so. There were some heated exchanges. What we got was an assurance from the Minister——

I will give a simple statement now.

He said "When we are dealing with the Bill I will make the position quite clear in relation to the card-holding people who want to go to the family planning clinics." As a result of prescriptions which they get at the family planning clinics will these people have the right to be supplied with whatever the doctor there may order? May they have a right of free access to these appliances, medicines, drugs or whatever he may authorise in his prescription? Do the medical card holders have these free?

I do not know why the Deputy keeps referring to clinics. Basically this Bill provides that the availability of family planning services will be from the general medical practitioner. A person will go to the general medical practitioner for advice and information about family planning matters and, if it is called for, for a prescription or authorisation. That person will then proceed with that authorisation or prescription to the pharmacist who will supply in the the normal way whatever is specified for which the person will pay. On the other hand, if a person is prescribed any drug or pill for medical reasons by the doctor and the person is a medical card holder, that person will have that provided free under the GMS as heretofore. There is no change in that.

Would the Minister clarify the position once more on this? For medical reasons he talks about going to a doctor and says that if a contraceptive is prescribed for medical reasons——

For reasons other than family planning. If it is provided for family planning reasons then the person pays for it on prescription.

Why is this so? Why should there be——

I have nothing more to say.

——a distinction? I presume "medical reasons" would be where a lady is worried, like in the McGee situation, about becoming pregnant because she may lose her life. Is the Minister making a distinction between the kind of situation where a doctor may say that a lady may lose her life if she has a child and the kind of situation where a lady states that she does not want to have more than one or two children? Will the latter person, even though she is in the card-holding class and is at present getting the pill free as a cycle regulator, have to pay from now on?

Any general medical card holder who has access to contraceptive drugs or pills is doing so for medical reasons. Otherwise, these things cannot be prescribed. In future, if a doctor prescribes any of these things for reasons other than family planning reasons, they come within the general medical service and will be supplied free. If they are supplied on prescription or authorisation under the terms of the Bill the patient will have to pay the pharmacist for them. I am certain that Deputy Browne does not like that position but we can go on ad infinitum with this argument. However, we always come back to the simple proposition which is involved here. I believe that contraceptives should be available for family planning purposes and that their availability should be controlled and limited. That is the manner in which I propose to control and limit them. Deputy Browne does not agree with that. He wants contraceptives made available in an unlimited way, and everything we say comes back to that central argument. Can we not, once and for all, dispense with it? Can he not understand where I stand, what I have in the Bill and what my approach is? He should vote against my approach or for it, as he sees it.

I must put the question. We cannot go on arguing about something which is not in the section.

I have not repeated myself once. I am replying to points made by the Minister, who made the case for the Bill that family planning needs to be supervised by a doctor. Therefore, the case presumably is that it is a medical need.

The Deputy asked me for clarification on a point of fact and I gave him it but he used my explanation to pursue further arguments. As far as I am concerned it is a time-wasting process supplying the Deputy with the information he seeks.

This is Committee Stage and I am within my rights seeking further information from the Minister.

There is nothing in the section dealing with what the Deputy is talking about.

The general principles of the Bill have been debated and a decision taken on them on Second Stage. We are dealing with sections now and the Deputy is inclined to concentrate on the principles which have already been debated. I must put the question.

The Minister has established that family planning is a medical need because he insists that a doctor be there to provide family planning advice. It is wrong to say that I am looking for unlimited provision of these services. I said I would like it, but I restricted my case to the medical card holder. Therefore, I am not suggesting that there should be an unlimited supply of these, even though my views are otherwise. In relation to medical card holders the Minister is attempting to establish that a prescription would be needed. The prescription usually implies the provision of something which is medically needed by the patient. Any other prescription given by a doctor to a patient under the medical card scheme would be paid for by the State. I should like to know why that does not apply in relation to family planning, which in certain instances according to all the authorities, the WHO, the UN and all parties here, should be a facility readily available? Those services should be provided for card holders free of charge and I should like to know why the Minister does not accept that in respect of family planning services?

We are arguing without any purpose.

I welcome the Minister's statement that he will examine the question I raised in relation to ensuring that the personnel who will give information in relation to the natural methods will have sufficient training and expertise. I find it difficult to follow the Minister's logic in allowing a doctor to charge for the giving of information and advice to a medical card holder or the writing of a prescription against the general medical services and not allowing the cost of dispensing the prescription or filling the authorisation. I could follow the Minister's logic if he decided that the making available of contraceptives was not a medical matter, but to follow that logic through he would also have to state that a medical card holder would be obliged to pay a doctor for a visit.

That would be introducing unnecessary complications. It is too fine a point.

I accept that it would be introducing unnecessary complications but there is not much logic in the Minister's argument.

My simple logic is that the provision of advice by a family practitioner under the Bill is permissible under the normal general medical service provisions but the supply of contraceptives will not be borne by the taxpayer under that service. It is a simple and clear-cut principle.

I would think that the Committee of Public Accounts or the Comptroller and Auditor General would find it difficult to follow the fact that I must pay a doctor for advice and signature on an authorisation for condoms——

That is a matter between the Deputy, a non-medical card holder, and the doctor.

I would be grateful if the Minister would give me the name of a doctor who will do that for nothing. I would have to go to a doctor and pay and then go to a chemist and pay. However, a medical card holder will not pay the doctor but must pay the chemist. I cannot understand the logic of writing an authorisation within the GMS as a charge against the GMS.

There is another matter that puzzles me. A woman who is a medical card holder can have the pill prescribed for her as a cycle regulator which also happens to have the effect of inhibiting conception. If a doctor decided that she no longer needs the pill for that purpose and she then asks to have it prescribed so that it may continue to inhibit conception she must pay the chemist. It is even more difficult to follow the fact that if she decides to discontinue the pill and her husband decides to commence using condoms, he must visit the doctor where he gets the advice and authorisation free but must pay the chemist for them. Does the Minister envisage a situation where a doctor within the general medical service might decide to prescribe the condom as a prophylactic.

I have explained my approach to this problem. If the Deputy wishes merely to spend time demolishing them, he is in conscience and honour bound to put forward proposals of his own.

I would hesitate to resort to the tactics used by the Minister's colleagues in 1974, the tactic of pointing out repeatedly that it was the job of the Government to govern and that it was not the task of the Opposition to put forward alternatives.

We are putting forward proposals.

But the House is entitled to clarification as to how the proposals are to be implemented. There is a complicated web in respect of medical card holders in relation to the operation of this Bill. I am assuming, for instance, that the fact that a doctor will be obliged to write on a prescription that it is being written in accordance with the Family Planning Bill, 1978, is to allow the pharmacist to distinguish between a prescription written in accordance with this Bill and which does not qualify in terms of a general medical service——

I am putting the section.

I am trying to have the situation clarified.

The Chair has been more than tolerant and has allowed discussion which is really not relevant to this section. The Deputies are discussing the principles of the Bill but I only allowed one point that was raised by Deputy Browne. The principles of the Bill were discussed at length on Second Stage.

I am happy to accept your ruling so long as you can give me some guidance as to when the point I have been raising can be discussed.

There will be a Report Stage.

But when, on Committee Stage, can this matter be raised?

The Deputies have spent one full day on it.

Discussion of the principles of the Bill cannot be permitted on section 3.

We are entitled to find out how the Bill will affect medical card holders.

Can the Deputy tell me in what way that question can be related to section 3?

I should have thought that section 4 would have provided the more suitable opportunity for discussion of this matter but having regard to the protracted discussion between the Minister and Deputy Browne——

For most of the time that discussion was relevant.

I would have preferred to have this question disposed of now but if the Chair is happy to allow me wait until we reach section 4, I am satisfied to wait until then.

The Chair does not think that the matter being discussed now should be raised again either on this or any other section.

I shall be happy to raise these matters on section 4, subsection (2).

I am putting the section as amended.

On a point of information, section 3 provides for the provision of a service and the Minister has made it clear that there will be a charge for this service. Surely we have a right to ask him to explain his thinking on this.

I permitted the Deputy to make that point and he made it although I thought it was a little outside what is contained in the section but the Minister replied and, consequently. we can now move on.

There is one final point which might interest Deputy de Valera. It was found in Great Britain and in the North of Ireland that there was a reduction in the abortion rate after contraceptives were made available freely and while it is not possible to regard this decrease directly as a cause-and-effect situation, it can be assumed that the relevantly free accessibility to the various forms of contraceptives was an important factor.

The Deputy is raising another matter.

Regarding the Chair's question as to how I related my remarks to the section, I have now read the section again and find that the question relates to subsection (1) which provides for the making of ministerial regulations in respect of the provision by the health boards of a family planning service. I am endeavouring to find out what way that service will operate in so far as the general medical card holder is concerned.

It does not include the supply of artificial contraceptives. Therefore, the question is not relevant.

This matter arises again on section 4 but I thought it would be better to dispose of it now.

I have nothing to add to section 3. I have replied to all the points raised.

The Minister did not clarify whether, for instance, a prescription for condoms prescribed as prophylactics would qualify in terms of the general medical service.

I am not interested in hypothetical medical questions and I do not think the Deputy is serious in addressing them to me.

I shall be asking the same question on section 4 in respect of the word "sale".

Question put.
The Committee divided: Tá, 66; Níl, 33.

  • Ahern, Bertie.
  • Ahern, Kit.
  • Allen, Lorcan.
  • Andrews, David.
  • Andrews, Niall.
  • Aylward, Liam.
  • Barrett, Sylvester.
  • Brady, Gerard.
  • Brady, Vincent.
  • Briscoe, Ben.
  • Browne, Seán.
  • de Valera, Síle.
  • de Valera, Vivion.
  • Fahey, Jackie.
  • Farrell, Joe.
  • Faulkner, Pádraig.
  • Filgate, Eddie.
  • Fitzpatrick, Tom
  • (Dublin South-Central).
  • Fitzsimons, James N.
  • Fox, Christopher J.
  • Gallagher, Dennis.
  • Geoghegan-Quinn, Máire.
  • Haughey, Charles J.
  • Hussey, Thomas.
  • Keegan, Seán.
  • Kenneally, William.
  • Killeen, Tim.
  • Lalor, Patrick J.
  • Lawlor, Liam.
  • Lemass, Eileen.
  • Lenihan, Brian.
  • Leonard, Jimmy.
  • Leonard, Tom.
  • Burke, Raphael P.
  • Callanan, John.
  • Calleary, Seán.
  • Cogan, Barry.
  • Colley, George.
  • Collins, Gerard.
  • Conaghan, Hugh.
  • Connolly, Gerard.
  • Cowen, Bernard.
  • Cronin, Jerry.
  • Daly, Brendan.
  • Leyden, Terry.
  • Lynch, Jack.
  • McCreevy, Charlie.
  • McEllistrim, Thomas.
  • MacSharry, Ray.
  • Molloy, Robert.
  • Moore, Seán.
  • Morley, P.J.
  • Nolan, Tom.
  • Noonan, Michael.
  • O'Connor, Timothy C.
  • O'Hanlon, Rory.
  • O'Leary, John.
  • O'Malley, Desmond.
  • Power, Paddy.
  • Reynolds, Albert.
  • Tunney, Jim.
  • Walsh, Joe.
  • Walsh, Seán.
  • Wilson, John P.
  • Woods, Michael J.
  • Wyse, Pearse.

Níl.

  • Barry, Peter.
  • Begley, Michael.
  • Belton, Luke.
  • Bermingham, Joseph.
  • Boland, John.
  • Browne, Noël.
  • Bruton, John.
  • Burke, Joan.
  • Cluskey, Frank.
  • Collins, Edward.
  • Conlan, John F.
  • Creed, Donal.
  • Crotty, Kieran.
  • Desmond, Barry.
  • Desmond, Eileen.
  • Donegan, Patrick S.
  • Fitzpatrick, Tom
  • (Cavan-Monaghan).
  • Gilhawley, Eugene.
  • Harte, Patrick D.
  • Horgan, John.
  • Keating, Michael.
  • Kelly, John.
  • Mitchell, Jim.
  • O'Brien, Fergus.
  • O'Brien, William.
  • O'Connell, John.
  • O'Leary, Michael.
  • O'Toole, Paddy.
  • Pattison, Séamus.
  • Quinn, Ruairí.
  • Taylor, Frank.
  • Timmins, Godfrey.
  • Tully, James.
Tellers: Tá, Deputies P. Lalor and Briscoe; Níl, Deputies Creed and B. Desmond.
Question declared carried.
SECTION 4.

Amendments Nos. 15 and 16 are ruled out of order.

I move amendment No. 17:

In page 3, subsection (1) (b) (i), lines 49 and 50, to delete "and the sale is at the place where he keeps open shop" and to substitute "for the compounding and dispensing of medical prescriptions in accordance with the provisions of the Pharmacy Acts, 1875 to 1977, and the sale is at the place where he so keeps open shop or at a place where family planning services are made available under section 3 of this Act."

The Pharmaceutical Society of Ireland asked that the phrase "open shop" used in the section be changed to provide a wording more in accordance with provisions of the Pharmacy Acts, 1875 to 1977. The first half of the amendment is designed to meet that request. The second half arises because during the course of discussion on the Bill it appeared that in certain circumstances it would be desirable, if a health board is providing family planning services in the clinic, that a pharmacist would attend there and supply the contraceptives in response to prescriptions or authorisations made out by medical practitioners.

My approach to sections 3 and 4 of the Bill is that family planning services in future will be supplied principally by the general practitioner to his patients as an integral part of our family doctor service. There is a need to supplement the service provided by the general practitioners and this situation can be met through clinics established under the health boards. There is also provision whereby other persons or bodies may be authorised to provide a family planning service. When I speak of family planning services being provided in clinics, whether they are under the control of the health board or otherwise, this does not include the sale of contraceptives at such clinics.

Anybody who wishes to organise family planning services not exclusively related to natural family planning will, under section 3 (3), be controlled in the provision of services and cannot organise those services except with the consent of the Minister in accordance with the regulations he will make. Under that subsection my consent will not be given unless I am satisfied that it is in the public interests to give it and that the service is reasonably required to meet a need. Any organisation providing family planning services under the section will have to comply with the provisions. They will be required to see that the service is under the general direction and supervision of a doctor if it involves the use of contraceptives and they will also have to ensure that the service covers natural family planning methods. Any organisation providing family planning services in the future will have to comply with section 7 of the Bill under which the advertising of contraceptives or contraception or the display of contraceptives and so on will be controlled.

Any organisation involved in family planning services under health boards or other bodies will not be allowed to go into the business of selling and providing contraceptives. This section clearly limits the sale of contraceptives to pharmaceutical chemists. It also sets out the limitations as to the circumstances and places in which contraceptives may be sold. It is essential that those agencies involved in providing family planning services should not have a commercial interest in the sale of contraceptives. The medical practitioners and clinics will issue authorisations or prescriptions for contraceptives but the pharmacist will supply them. This amendment will allow pharmacists to sell contraceptives at a place where family planning services are organised. This is simply for the mutual convenience of pharmacists and the general public and will not cut across the principles which I have outlined.

When this Bill is enacted I will consider in detail whether there is any need to organise clinics under section 3 (3) for the operation of family planning services outside the health board system. This will have to be done in the context of the legislation with full consideration being given to those who wish to adopt natural family planning methods and will have to conform with the ordinary organisation of the family planning service provisions of this legislation. If any clinics are to be authorised they will be subject to the provisions of this legislation in regard to the sale of contraceptives and advertising. If any organisation now providing family planning services wish to continue to do so, they will have to apply for a licence. I will examine any such application under section 3 (3) and, if it is clearly established that it is in the public interest that it should be authorised, they will have to comply fully with the provisions of the legislation mainly in regard to doctor's prescriptions or authorisations, sale through pharmacists only, medical supervision, natural family planning advice being emphasised and provided, and control of advertising.

It has been suggested that this amendment as framed might make it possible for a particular clinic to become the agent of a pharmacist and therefore to be able to supply contraceptives. That is not intended. If on further consideration that appears to be so, I shall have to introduce a further amendment on Report Stage to make the position absolutely clear.

A number of people will be either very vexed or very pleased by the Minister's explanation of the intention of this amendment. When I first read it my interpretation was that the Minister had put forward a device whereby the existing family planning clinics could continue to supply contraceptives through acting as agents for a chemist, or where they entered into some suitable arrangement with a chemist and that chemist is satisfied that the clinic is operating in a responsible manner. During Second Stage the point was made to the Minister that before a clinic could operate under section 3 (3) it would have to obtain a licence from him. Obviously that would not be forthcoming unless the Minister was satisfied as to the manner and make-up of the clinic and unless he was satisfied that the personnel operating the clinic were doing so in the public interest and in a manner consonant with his thinking in relation to this legislation. The point was made forcefully, especially by Deputy Browne, that at the present time the clinics derive much of their income from the sale of contraceptives following the imparting of advice in relation to them and that if they were to lose that revenue it would have serious financial consequences for their future viability.

All of us appreciated the Minister's difficulty in that he was almost certainly experiencing a degree of difficulty and opposition from within his own party in relation to how far he might go in the licensing of clinics or how he might authorise them to operate in the future. I must confess that when I read this amendment to section 4 I thought the Minister had come across with a rather clever device whereby he could allow clinics to be licensed, that by adding this amendment to section 4 the clinics could make an arrangement with a pharmaceutical chemist whereby they would act as his servant or agent and dispense contraceptives and perhaps in certain instances the chemist might attend at the clinics in order to conduct that sale.

It appears now from what the Minister has said that his intention was not as far-reaching and, on the face of it, his device by way of the amendment was not as devious and clever as I had thought. The Minister is claiming it is not his intention to allow the clinics to operate the sale of contraceptives but merely that they might make an arrangement with a pharmacist so that he could dispense contraceptives at the clinic for the convenience of the public. I am presuming the Minister is saying he wanted to get over the objection that I and other speakers raised of a person going to a clinic for advice, of then going to a doctor, leaving him to go to a pharmacist in order to get the contraceptives, and that in order to short-circuit that route he is hoping a doctor and a pharmacist would be in attendance at the clinic at all times.

The Minister now appears to be at pains to point out that it is not his intention to allow the clinic to act as a servant or agent of the pharmacist. If that is so, the guarded welcome that some people were giving the amendment will be even more guarded. Irrespective of whether or not that is the Minister's intention, there is no doubt in my mind that that is the effect the amendment would have and that is the effect in law that the amendment would have when read in conjunction with the subsection. If passed the section would read:

4. (1) A person shall not sell contraceptives unless—

(b) (i) he is, or is a servant or agent acting as such of, a pharmaceutical chemist, or a dispensing chemist and druggist, who keeps open shop for the compounding and dispensing of medical prescriptions in accordance with the provisions of the Pharmacy Acts, 1875 to 1977, and the sale is at the place where he so keeps open shop or at a place where family planning services are made available under section 3 of this Act.

There is no doubt that, if a family planning clinic were to persuade a pharmacist to appoint them as his agent or servant, under a strict interpretation of that amended paragraph they would be entitled to carry out the dispensing of contraceptives. Of course the profit, if any, would accrue to the chemist unless he wanted to make some private arrangement to forego it and to devote it to the clinic.

It is difficult now to know the full intent of the Minister's amendment. He is saying now that his intention in the amendment was less than we envisaged when we read it and that, if the amendment has the effect that it appears to have on the section, he will further amend that amendment on Report Stage. That makes this already complicated Bill even more difficult to deal with. It would be helpful if the Minister in the course of this discussion made his intention clear to us as to whether he thinks the amendment will have the effect which I have stated it will have and, if it is going to have that effect, whether we are to assume there is to be a further amendment on Report Stage. Certainly it leaves the House in a very difficult position.

As I have said, the amendment is simply intended for the convenience of the pharmacist and his clients. It has been pointed out to me that an interpretation of it might mean that a clinic could be deemed to be the agent of a pharmacist and therefore would be entitled to actually supply contraceptives. That is not my intention. If on further consideration that argument appéars to be sustained, I shall have to bring in an amendment on Report Stage to make sure that what I intend is given effect to fully.

Like Deputy Boland, I assumed that this was an amendment which was intended to make it possible for the family planning clinics to survive. Their source of financing stems from their capacity to sell contraceptives. They have provided an excellent service. It appears now that the Minister is positively vindictive about these clinics and, lest they might be able to come to some arrangement with the chemist by acting as his agent and in that way earn enough money to keep their doors open, the Minister is deliberately going to circumvent that possibility.

If that is the Minister's intention it seems to be an extraordinarily vindictive approach to adopt about a service which all of us must admit was way ahead of its time. It was provided because it was needed and not, as this Bill appears to have been provided, simply because of a Supreme Court decision. The service provided in the clinics is remarkably economical. They are well run and administered. Nobody could fault them on the quality of the professional standards maintained on the nursing, social welfare and medical sides. They give psychosexual advice and provide services for examination of breast and cervical cancer; there is pregnancy testing.

Why does the Minister reach out in this way to prevent these people from providing this very valuable service when it does not appear that he would be able to provide a service for a very long time? The service provided by these people is recognised by his Department. Training carried out by them in their clinics is recognised by the Minister's Department in regard to the recoupment of the cost of fees and so on of medical and other personnel taking the recognised course of the Joint College of General Practitioners and the College of Obstetricians and Gynaecologists. Even accepting the Minister's strange provision that there must be a medical practitioner prescribing for medical and non-medical contraceptives within a clinic, why is it that he will not facilitate these people in keeping existing services going by allowing them to come to some arrangement with the chemists? A financial arrangement could be worked out between them, possibly in the form of an agency, which would allow them to carry on.

The suggestion that he will bring in an amendment to his own amendment is a window on the Minister's mind which indicates he is particularly anxious that these clinics should cease to provide a service. If this is so and the rest of the Bill stands and existing clinics are put out of action, the situation will be completely hopeless. It is very difficult to understand in any terms why the Minister is doing this. It has not been suggested by anybody in the course of this debate that these clinics are not providing a very fine service, within the limitations of their facilities and their financial situation. In addition to the service provided for the 11,000 or 12,000 who visit the clinics, there is a postal service, when such is possible, and various other facilities. Why should the Minister set out to close these clinics, as appears to be his intention?

I support what the Minister says on this and I am quite clear about his intention. From a drafting point of view, I would be very unhappy about the amendment as it is. The Minister's intention is impeccable.

Deputy Browne is attributing all sorts of motives to me. He wishes to conduct this debate entirely on the basis of my mentality, my motives, feelings, ethics, even my moods. That is not constructive.

It is very difficult to keep track of them anyhow.

I am not setting out to be vindictive to anybody in this legislation. I am bringing in the legislation to meet an urgent social problem, even a medical problem. In dealing with that problem I have enshrined in this legislation certain principles. One of these principles is that contraceptives shall be made available only on a doctor's prescription or authorisation and then shall be available only through pharmacists. That is the basic principle of the Bill and all the huffing and puffing here in the Dáil will not change that approach. If I were to change that principle I would have to abandon the legislation entirely and come forward with some completely different set of proposals.

If it is necessary for a health board to establish a family planning service clinic they will have to adhere to that fundamental principle. If it transpires that some other group of persons, organisation, body or hospital feel that there is a need for the provision of a family planning service in a certain area or in a certain way and they wish to establish a clinic, they will have to get a licence and conduct that clinic in accordance with the principles of this legislation. I do not believe that it is in any way difficult for any family planning clinic to conduct their affairs in future under the legislation in accordance with the principles of the legislation.

I do not think it is desirable that we should have a clinic supplying or purporting to supply important medical services supported only on the sale of contraceptives. I say this en passant because it will not be relevant once the Bill comes into effect. Does anyone think it is desirable that in order to supply a range of fundamentally important medical services a clinic comes into existence and is enabled to do so by the sale of contraceptives, which nobody else can sell because the law prohibits it? I do not think that is a desirable situation.

This Bill will bring about a situation where family planning services will be provided comprehensively for all people as they are needed and provided in accordance with the principles of this legislation. If any group of persons, whether running an existing clinic or not, wish to provide any service in the family planning field they will have to get a licence and conform to the provisions of this legislation, which make a clear distinction between the provision of family planning services and the sale of contraceptives.

In view of the Minister's extraordinary statement in introducing this amendment, it would be far better to consider withdrawing it. He tells us that he will almost certainly have it amended and that seems to be confirmed by the remarks of Deputy Vivion de Valera. Apart from our acceptance or otherwise of the Bill, it might be better for our comprehension of how it will finally turn out if the Minister were to withdraw this amendment and tell us what he intends. It appears as if the Minister made an attempt at meeting some of the case that was made and is now being made to withdraw from that position once again. It might be more helpful to the House to withdraw this amendment and introduce an amendment which he thinks he can successfully put before the House.

I will be going ahead.

Progress reported; Committee to sit again.
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