Termination in Cases of Foetal Abnormality: Mr. Peter Thompson, Birmingham Women's and Children's Hospital

I welcome members and also viewers who may be watching the proceedings - I did not welcome them earlier on - to the Joint Committee on the Eighth Amendment of the Constitution. We will be holding two separate sessions this afternoon and we will first hear a presentation on termination in cases of foetal abnormality from a consultant in maternal foetal medicine. Our second session will be with officials from both the Department of Education and Skills and the Department of Children and Youth Affairs to consider the ancillary recommendations of the Citizens' Assembly.

Before I introduce our first witness today, at the request of the broadcasting and recording services and at the risk of serious repetition, members and visitors in the Public Gallery are requested to ensure that for the duration of this meeting their mobiles are fully off. We have seen that they interfere with the footage. Please be accommodating with that.

I extend on behalf of the committee a warm welcome to our first witness to present to us at this afternoon's meeting, Mr. Peter Thompson, consultant in maternal foetal medicine, at Birmingham Women’s and Children’s Hospital, who will address the issue of termination in the case of foetal abnormality. You are very welcome to this meeting this afternoon and thank you for travelling over to be here.

Before we commence formal proceedings I must begin with some formalities and advise our witness on the matter of privilege. I will go through this quickly. I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if you are directed by the committee to cease giving evidence in relation to a particular matter and you continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against any person, persons or entity by name or in such a way as to make him or her identifiable.

Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I now call on Mr. Thompson to make his presentation.

Mr. Peter Thompson

I thank the committee for inviting me today and allowing me to contribute to this pivotal decision that Ireland as a nation is about to address concerning women's rights. I am a consultant in foetal medicine practising in England at Birmingham Women’s and Children’s Hospital. My special interests are in the prenatal diagnosis and management of foetal disease, the management of women with congenital heart disease and the management of multiple pregnancies. Within my management of foetal disease, is included the diagnosis of differences in the foetus by ultrasound scan, preforming invasive prenatal diagnostic techniques such as amniocentesis and chorionic villus sampling, CVS, performing invasive prenatal sampling such as drainage of fluid collections within a foetus which may be life threatening and also, where appropriate, counselling with regards to termination of pregnancy.

The unit where I work, Birmingham Women’s and Children’s Hospital is in the West Midlands and delivers approximately 8,000 women each year.

The West Midlands has a population of 5.5 million and my unit is the regional foetal medicine unit. We perform over 7,000 ultrasound scans, 410 invasive procedures checking the chromosomes of babies, 48 intrauterine blood transfusions and around 40 fetoscopic laser ablations. We also perform a number of other invasive tests, included selective reductions which I may mention later. The unit is a supraregional referral centre for the management of feto-fetal transfusion syndrome and its management by fetoscopic laser ablation.

I have had an opportunity to present to the Citizens' Assembly and I am happy to discuss with the committee the care pathways of the termination of pregnancy under clause E in England, the experience of some Irish women that we have come into contact using these services and some suggestions regarding the use of the term fatal or lethal abnormality. I do not intend in my introduction to cover all of the aspects that I covered in my paper. Having said that, I am happy to expand on that with questioning.

I am sure that all of the members are aware that 40 years ago the Westminster Parliament passed a Private Members' Bill ensuring that doctors who performed abortions, under certain conditions, would not be performing an unlawful act. This law has never been adopted in Northern Ireland. The law was subsequently amended by the Human Fertilisation and Embryology Act 1990. It is still an offence to perform an abortion unless two independent medical practitioners are of the opinion, formed in good faith, which is an important phrase, that the case meets at least one of the required criteria.

I hope to speak to the committee about clause E which states: "there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped". The British Parliament has never sought to define what is meant by the words "substantial" or "serious". The matter has been left to be decided in good faith by the medical profession.

It is important to note that clause E of the termination Act is not gestation dependant. According to the Office for National Statistics in the UK, as many as 190,000 abortions were performed in England and Wales in 2016. Of these, however, only 3,200 were performed under clause E. As in the Republic of Ireland, the main foetal anomaly ultrasound scan is performed at approximately 20 weeks gestation in England and Wales. Despite this only 500 of the 3,200 abortions, that I have mentioned, were performed after 22 weeks of pregnancy. Also, there were 140 selective terminations of pregnancy, involving multiple pregnancies and over three quarters of these were under clause E. These can be life-saving procedures for the co-twin and I have described one such case in the case studies that I have submitted. Over half of these terminations of pregnancy are performed for chromosomal or central nervous system differences in the foetus.

In 2016, 3,265 Irish women had a termination of pregnancy in England and Wales. Of these 140 had a termination under clause E of the Act. Again, the foetal indications are predominantly chromosomal or central nervous system differences.

As explained in previous sessions that I have read, detailed anomaly scans of foetuses are performed at approximately 20 weeks gestation, though the availability appears to be much less in Ireland than it is in the UK. In England and Wales if a difference is found in a foetus, a pathway is followed that may include a second local scan to confirm the diagnosis by an obstetrician with a special interest in fetal medicine. The second scan should be performed within five working days. In some cases local obstetricians will be able to fully counsel women on the outlook for their baby. In other cases, referral to a recognised foetal medicine unit will take place.

We attempt to see women within three working days at my foetal medicine unit and that is the standard that has been set nationally. When we see these women we scan them, then sit them in a more homely room and counsel them and their families in the presence of a midwife. All options are discussed with the women including, where appropriate, intrauterine foetal therapy and the termination of pregnancy. On leaving the woman is given a detailed report that is read through with her prior to her leaving and contact numbers for the fetal medicine centre are given. A sub-group of women may need additional investigations, both invasive and non-invasive, and some will require counselling by a specialist in another field. It is important to acknowledge that women will need differing amounts of time to come to terms with this information and make their decisions.

If the woman opts to terminate her pregnancy this will be arranged at her local unit where she can get additional family support. Depending on the gestational age, both surgical and medical termination techniques are discussed with these women. As there is an increasing chance of foetuses being born alive after 22 weeks of gestation, the Royal College of Obstetricians and Gynaecologists recommends that the foetal heart is stopped by performing feticide prior to the termination of pregnancy for cases after 22 weeks of gestation unless the abnormality is not compatible with life.

If the woman opts for a medical termination of pregnancy then a tablet, an anti-progestagen, is administered and admission arranged for induction of labour with prostaglandins about 36 hours later. Around 95% of women will deliver on the day they receive their prostaglandins. A small proportion will require a second course. An infection, haemorrhage and retained placental tissue are the main short-term complications of the procedure. For the Irish women that we see in our unit, we complete the termination process in Birmingham but once discharged the women return to Ireland. While in Birmingham, they often express the difficulties that they have with regard to the limited number of people who they can discuss this scenario with and gain support from.

Finally, I would like to mention the concept of fatal or lethal conditions. If the law in Ireland is to change and the termination of pregnancy is allowed for foetal differences, I would urge the committee not to make a list as with the ever changing progress in medicine conditions would need to be added and removed from the list on a regular basis. I would also strongly advise against being prescriptive and using the term lethal or fatal abnormality. The problem is there is no agreed definition as to what lethal means. Does it mean that all foetuses with the condition will die before birth? Does it mean that all foetuses will die either before birth or in the neonatal period despite supportive therapy? Does it mean that a baby will usually dies in one of these two periods? Finally, has it just been noted that there is an association between the condition and death?

For the information of members, I included two tables from a publication by Wilkinson et al in the paper that I submitted to the committee. The first of these lists the commonest conditions named in the medical literature that is said to be lethal foetal malformations. The same paper quotes the longest age of survival for these conditions, and since this publication survival until 13 months has been reported in a case of renal agenesis. Therefore, counselling women whose pregnancies are complicated by a foetus with a severe abnormality is not a binary state of affairs but rather a complex discussion that requires a description of risk and probability.

Last year, over 3,000 women travelled from Ireland to England to terminate their pregnancies. Approximately 140 of them had a termination because their foetus was thought to have "a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped”. The care pathway that is followed by Irish women is sub-optimal, removes them from their support network and is only available to a sub-set of women who are able to initiative their contacts with units in England.

Finally, if legislation is brought in for foetal conditions, particular care must be taken when using the phrase "lethal or fatal".

I thank Mr. Thompson for his presentation. The first questioner for today is Deputy Kelleher. Does he wish to share time?

Yes, I might share my time later today and members can avail of my remaining time if I am not here.

Will Mr. Thompson elaborate on the observations and statements he made towards the end of his contribution urging us not to itemise the conditions that could be reasons for a termination. Is he saying that it is clinically impossible to diagnose and differentiate between a fatal condition and a very severe foetal condition?

Mr. Peter Thompson

The first thing is to decide what is the definition of "fatal". As a result of the history of the law on abortion in Ireland, it will be very difficult for Ireland's obstetricians to decide. If it is decided in law that a fatal condition is one in which the baby always dies in utero, then we must consider that those conditions are exceptionally rare. As the committee can see in the other table I submitted, even babies with trisomy 18 have been noted to survive following birth, although very rarely. I worry that if the term "fatal" is used, some would argue that everything is fatal. The contrary argument is that nothing is fatal because it does not result in a death in every single case. A baby could live for a short period after birth. That is my main consideration about the term "fatal".

There was a first part to the question. Is it impossible to draw up a list? One could draw up a list of severe conditions if one could decide on one of those four different definitions. One could draw up a list of severe conditions that would be appropriate for termination of pregnancy in Ireland. The problem is that more conditions are being diagnosed all the time. Another condition might then need to be added. Alternatively, we might find a cure for one of the conditions on the list. I am concerned that legislators in Ireland would constantly have to revisit the list in a circular fashion trying to tick things off and put things on. In my experience of legislation, that can take quite a considerable amount of time.

Clause C was amended by the UK Human Fertilisation and Embryology Act 1990. Mr. Thompson said it is important to note that only clauses C and D are gestation dependent. Is it correct that clause E is not gestation dependent?

Mr. Peter Thompson

That is correct.

Is it correct that when Mr. Thompson, as an obstetrician, is diagnosing a foetal abnormality, the 20-week anomaly scan will identify most of these abnormalities?

Mr. Peter Thompson

Depending on which abnormality it is, there will be a different proportion diagnosed. With cardiac abnormalities, it is much lower than 50%.

What is the latest point of gestation at which all potential foetal abnormalities can be diagnosed?

Mr. Peter Thompson

They will never all be diagnosed on ultrasound but some women will not present until after 24 weeks. Women who do not present until later in pregnancy tend to be those who have poorer socioeconomic backgrounds, such as those who are refugees. Generally speaking, people who are less privileged in society will present later on and have poorer pregnancy outcomes overall. If there is a gestational age limit that is lower, those women would be disadvantaged.

Am I right in saying that the NHS gives free anomaly scans to all women?

Mr. Peter Thompson

Yes.

At what stage of gestation does that anomaly scan take place? Is it at 12 weeks or 20 weeks?

Mr. Peter Thompson

In the UK, women have scans at 12 weeks, which is predominantly for dating. In addition, women are offered that test as part of a combined screening test that measures age, the thickness at the back of the foetus's neck - the so-called nuchal translucency - and markers of hormones in the woman's bloodstream. That will give the likelihood of the risk of the baby having Down syndrome, Edwards syndrome or Patau syndrome. One does not have to have that test. In our unit, only about 60% to 70% of women take up that test but they still have the scan for viability. In addition to that, women get a detailed anomaly scan between 18 and 22 weeks, which most units try to perform at about 20 weeks.

Is Mr. Thompson saying that, in his clinical experience, it would be pointless to have a cut-off period of 12 weeks' gestation for foetal abnormalities in view of the fact they cannot be diagnosed definitively until at least up until 22 or 24 weeks?

Mr. Peter Thompson

Some foetal abnormalities are diagnosed at 12 weeks but very few.

I thank Mr. Thompson for appearing before the committee and for his evidence. We are very interested in hearing the facts on this committee and Mr. Thompson has outlined them comprehensively. If my math is correct, according to the statistics Mr. Thompson gave us, 55% of terminations under clause E, which represents a very small number - about 1.7% - are performed between 13 and 19 weeks. That is the majority. Will Mr. Thompson outline whether there are follow-up scans? Deputy Kelleher and I share concerns about the availability of scanning equipment and access to scans for Irish women. We are told by management in the HSE that 20-week anomaly scans in many cases are offered where they are clinically indicated. Is there anything that would give a clinical indication? My understanding is these anomaly scans are screening scans and there will not be any form of clinical indication. If there is some form of clinical indication, and Mr. Thompson is the expert in this regard, he might share it with us.

Could Mr. Thompson define what constitutes the neonatal period? He referenced this in his submission. Is it in terms of development or weeks? We are fully cognisant of the issues Mr. Thompson has outlined in the context of making lists and how prescriptive and unhelpful it might be to clinicians but we are equally charged with considering recommendations from the Citizens' Assembly. Mr. Thompson is aware of those recommendations. Some relate to conditions resulting in death before or shortly after birth. Whether it is a good or bad idea is really a matter for the citizens because that is what has been given to us. We have to consider that and we have to contemplate what recommendations we will make and how they will translate into the medical community. I fear that as we are sitting here trying to come up with the report, there are doctors and clinicians watching proceedings at home, tearing their hair out and shouting at the screen that this will not work for them in practice. We want to be respectful and mindful of the recommendations of the Citizens' Assembly but we equally have to come up with something that is fit for purpose and which translates into medical practice for people. Perhaps Mr. Thompson will give us the benefit of his experience in grappling with that particular dilemma.

Mr. Peter Thompson

I think there were four questions. I will take them in reverse order. The issue of death before or after birth could be helped if the word "usually" was added.

That gives a degree of scope because nothing - or very few things - in medicine is 100%. If one said "usually death before or after", that would help the committee's recommendations tremendously. In talking about the neonatal period, we generally speak about the first four weeks of life.

For the first two questions I have written down "clinical indications". What was the Deputy's second question?

It relates to the fact that scans are offered in most instances where it is clinically indicated.

Mr. Peter Thompson

It is possible to pick cohorts of women who are statistically more likely to have a baby with a difference, for example, diabetic women or it may be people who have congenital heart disease and who would be significantly more likely to have a baby with that disease than would a woman with a normal heart. In relative terms, however, the majority of foetal abnormalities will still not be detected because the majority of foetal abnormalities will occur in a low-risk population just because there are more low-risk women. That is why the UK screening programme would strongly recommend everybody having a scan at 20 weeks.

We can all endorse that.

Mr. Peter Thompson

I am afraid I missed the Deputy's first question completely.

I only have scribbled notes. I think that was my first question - on the scans. I know Mr. Thompson is here specifically to discuss clause E. However, he mentions that clauses C and D are gestation dependent. How is that dated? Is it simply from the date of the last period or by scan?

Mr. Peter Thompson

It is on best dates. Best dates would be determined really by ultrasound scan in the first trimester. The best way to date a pregnancy is between 11 and 14 weeks by an ultrasound scan. If that is not possible, the dating becomes less and less accurate as time goes by. Effectively, I explain it to my patients as follows. With a small child, it is possible to tell roughly how old he or she is by how tall he or she is. That is the same up until approximately 24 weeks; we can determine how old a foetus is by its size. However, the standard deviation broadens quite significantly after that time. It would not be possible to tell the ages of those of us in this room by our heights. Later in gestation, it is necessary to do something else. Up until 24 weeks, the best way to do it is by ultrasound. In the UK it is by ultrasound scan.

I thank Mr. Thompson for coming over today. Some of the conversations we are having here seem to be on preconceived parameters and I am not sure who put them in place in this country. Based on Mr. Thompson's evidence, he seems to have dedicated his life to saving life during pregnancy, including the mother's life.

I am assuming that foetal-to-foetal transfusion syndrome means twin-to-twin transfusion syndrome.

Mr. Peter Thompson

Yes.

I have only heard of it described as twin-to-twin transfusion syndrome before. Mr. Thompson is dedicated to saving life and we are having conversations here about term limits, gestational stages, survival rates and all of that. I am concerned that we are trying to frame our work into a preconceived diagram and, at this stage, there is no need for that. We should trust experts in their field, such as Mr. Thompson, to progress their education and progress medicine. I am starting to think we should just let the doctors, the experts, deal with this.

Has Mr. Thompson ever encountered a person in the UK who has been compelled or forced against her will to terminate a pregnancy? There is almost a narrative here - this is obviously non-evidence based from what I can see - that doctors might be encouraging people to terminate. However, based on Mr. Thompson's evidence, it appears that he does a lot of work to counsel people, advise them on their situation and help them through it. I ask him to speak to that.

I also ask him to speak to the psychological and mental stress on families - mothers, fathers and other children - that can arise from a diagnosis of foetal abnormality, usually fatal. Does he have any figures for marital breakdown as a result of such a catastrophic diagnosis? The previous speakers mentioned this and I have spoken about it previously. With advances in medicine, children are surviving from just over 24 weeks, which would have been unheard of a decade ago. I support my colleagues in that we have to be very careful about putting in parameters, particularly when medicine is advancing so quickly and when children who would not have survived ten years ago might survive in the future.

As Deputy O'Reilly said, the 20-week scan is not available outside of the Dublin hospitals. Professor Louise Kenny from Cork addressed the Joint Committee on Health on this matter. Mr. Thompson spoke about diabetic women and other women with congenital defects themselves. We are missing one per week in Ireland where it is the wild card. It is the 20-year old who has a child with whatever condition. Clearly, we have issues in this country with 20-week scans. I do not want to misquote Professor Kenny, but I think her words were that one child a week is being born in circumstances that are not ideal and that these children should obviously be delivered in our teaching hospitals. I ask Mr. Thompson to address those points.

Mr. Peter Thompson

I wish to add to the Deputy's final point. As a junior doctor, I found it was quite difficult to come to terms with risk and why certain people have babies with abnormalities and who are the high-risk people. The easiest analogy I can see in our practice is that everybody talks about older women being at increased risk of having babies with Down's syndrome. However, most babies with Down's syndrome are born to younger women. That is because younger women have more children. It is just a factor of how many children are born in that cohort. If only women over a certain age are screened - when I started my career it was those over 37 in the UK - then the majority of babies with Down's syndrome will not be picked up.

I am trying to work backwards through some of the questions. There are figures on marital breakdown. I think there are well-published figures on marital breakdown in families where a baby has been born with trisomy 21. I would not like to quote what they are, but they are definitely there. The psychological and mental stress that people go through when they have a baby with a difference is huge. I do not want to talk about clauses C and D, because that is not part of my practice any more. However, the babies in the cohort we are talking about are very different because these are wanted babies where women have gone a significant part of the way through their pregnancies telling their families they are going to have a child and when the child is going to be born.

They then get this devastating news that the baby has some major difference. We should not be sidelined by the occasional story of babies with talipes or cleft lip or the like, we should be concentrating on the major differences that these babies have. More than half of them have significant chromosome or central nervous system differences. This puts the parents under huge stress and makes it difficult for them to make these decisions. We never give a diagnosis and then agree to a termination on the same appointment unless we are giving a second opinion to another centre. If people had been given a diagnosis at another centre, decided that they wanted somebody else to check, and had already been given all of the information, then we would agree to terminate at that point. Otherwise, however, we make parents go away and think about things.

In response to the question on preconceived parameters and leaving matters to the medical profession, I think that the medical profession in Ireland would want some support from the Legislature. I come back, however, to the section of the Human Fertilisation and Embryology Authority Act, HFEA, which talks about two independent clinicians coming to an opinion formed in good faith. I can essentially make a decision that could be wrong but if I have done so in good faith then I would be acting within the law. This is very important because we as a profession try to keep up to speed with professional development - I would like to think that I certainly do. Nobody gets everything right all the time, however, and we have to acknowledge that. None of us in any walk of life would say that we are perfect, but if a doctor makes a decision in good faith then that is what the law needs to protect.

I thank Dr. Thompson very much.

The Deputy has another minute or so.

God, I never have extra time.

We are very impressed.

Dr. Thompson mentioned foeticide being performed prior to the delivery of a child with complex abnormalities. We have heard testimonies about injections through the heart and graphic descriptions of cutting up dead unborn children. I wonder if Dr. Thompson could expand on the use of foeticide. Who is benefitting here: the mother; the doctor; the child? What is the holistic approach to early delivery or late termination, or whatever it is that we want to call it? I ask Dr. Thompson to expand on this because there has been much conversation about it being a very barbaric act, though I am sure that Dr. Thompson might disagree with that.

I ask Dr. Thompson to be as brief as he can.

Mr. Peter Thompson

Foeticide is performed when one is terminating a pregnancy after 22 weeks of gestation. We tend to do this under ultrasound control and gain access to the foetal circulation, sometimes through the heart. It is important that one then paralyses the foetus by administering a drug much as one would with a general anaesthetic, followed by an injection of either a local anaesthetic or potassium, which stops the heart. Once the foetus is born it becomes a baby and it is important to realise that whereas the foetus has no rights in the United Kingdom, the second it is born it acquires full rights. In the UK, then, one might end up with the scenario in which a woman undergoes a termination of pregnancy without the performing of foeticide only for the baby to be resuscitated afterwards. One would then have turned a scenario involving a foetus with an abnormality into one involving a premature baby with an abnormality, thus making the whole situation worse. Foeticide is not something that people like myself enjoy because we did, after all, go into our profession in order to try to save lives. On rare occasions, however, I think it is necessary.

Dr. Thompson does not favour the use of the expression "fatal foetal abnormality". What does he consider an appropriate term for people to use here? I know that this is a difficult question, but is there a more appropriate term?

Mr. Peter Thompson

I would go with the UK terminology: "a substantial risk of serious handicap".

That is quite a mouthful in a debate.

Mr. Peter Thompson

Does the Chairman mean what expression to use when one is talking to a patient, or what expression should be encompassed in law?

When we were putting a title on today's session, for example. What is the best language to use in the context of a debate? I know that this is not something that-----

Mr. Peter Thompson

One could use words like "serious" or "severe".

What about "incompatible with life"? Is that not an expression that Dr. Thompson would favour?

Mr. Peter Thompson

Some people would determine that expression as meaning that every baby in this category would always die the second it is born.

The question I am asking is obviously very difficult but I am wondering if there is better terminology that we could use in this debate.

Mr. Peter Thompson

I have given the committee four definitions of fatal as taken from the literature. If the committee were to decide on one of these definitions and stick to it then I think that it could use the word "fatal". It has to decide what fatal is, however, before it can use the term.

I call on Deputy Smith. She has ten minutes.

I thank Dr. Thompson and I found his contribution very interesting. Following up on his last point, I think he has touched on something very important with regard to how we define what is fatal. Dr. Thompson is absolutely correct - once we are born we are all fatal. To try to put legislative structures on words and definitions can, as Dr. Thompson has recounted from his own experience, take a very long time. There was a case in Britain some time ago - I cannot remember the name - in which debate and discussion of legislative changes in the High Court resulted in a long period of suffering for a woman and her child. I would like to say openly to everybody here that we have to be careful about the words we use when we are advising on the kind of legislation we want and we have to be mindful of some of the matters that Dr. Thompson has pointed out. He has pointed out some very serious issues that we have to grapple with here. One that struck me was the fact that some women present late with crisis pregnancies involving severe foetal disability because of poorer socioeconomic conditions. We have to be very mindful of such cases because, in looking at how we structure some kind of legislation, we have to remember that the Citizens' Assembly very passionately wanted it added to the discourse that socioeconomic factors play a major role in forming the outcome of their discussions.

I would like to pick up on a number of points, some of them in the same vein as Deputy O'Connell's questions about foeticide. I understand that an injection goes straight into the heart and stops it beating. This injection is lethal - it paralyses the foetus and kills it. Is there evidence, however, that such an injection causes pain? I ask Dr. Thompson to expand on the discussion of pain because it is often used in a very emotive way to argue against the treatment of pregnancy in this way. I would also like Dr. Thompson to expand an another important point. Women often look for options after they have had a scan at 20 weeks and they might need a follow-up scan very quickly within five days. This is often not available to them in Ireland, however, and that puts them at a big disadvantage.

Although they may go to Britain and have that, they need the follow-up care, discussion and conversation, to have the important emotional, physical and medical understanding of everything they are going through. Would Mr. Thompson agree that because they are forced out of Ireland and cannot get that care at home, where they are surrounded by family and other supports, they are particularly disadvantaged? Those who talk about cruelty to a foetus or an unborn child often use the word "baby" but we have to also think about the cruelty to the woman who is being denied access to this kind of reproductive health. I would like Mr. Thompson to comment on those points.

Mr. Peter Thompson

If we talk about late diagnosis, some conditions only present late. The other case that I described in the papers, microcephaly, whereby the brain is not growing normally, usually only presents after 24 weeks. Even if a woman has a history of having a previous baby with this, in many cases she has a 1:4 chance of having another baby affected in the same way. We would have to scan those women all the way through their pregnancy. Sometimes the head size appears normal until they get as far as 28 or 32 weeks and suddenly it becomes apparent that the baby has microcephaly. That is important.

With regard to foetal awareness and pain, the Royal College of Obstetricians and Gynaecologists has studied the literature on this, and regularly comes out with definitions of it. Last time it said the evidence that the foetus can and does experience pain is less compelling and accordingly the benefit of administering analgesia is less evident while the risk of the practicalities of so doing remain. On the basis of first do no harm, prior to the procedure described in this report, analgesia is no longer considered necessary from the perspective of foetal pain or awareness. The previous report had suggested that we should give analgesia to the foetus in case the foetus felt pain. After that it suggested that it was not necessary. I am not an expert on foetal pain but that is the Royal College of Obstetricians and Gynaecologists' position.

I think Irish women are greatly disadvantaged. In the UK, not long ago, there was, and there still is, a shortage of sonographers and many units stopped doing 20 week scans. We have had to train up many of our midwives who perform ultrasound scans to get a new cohort of professionals to do this. It should be something that is available to everyone. Ultrasound depends on how large the woman is, in women who are overweight the views are less good. Women are often brought back for a second look. We talked about doing it between 18 and 22 weeks but if we do it at 18 weeks we have to bring back a greater proportion of women for a second look and we end up doing more scans overall. That is why most people settle for around 20 weeks as their best evidence.

I note that a post mortem on the foetus is often recommended for medical information for future pregnancies. Sometimes the information that might result from that post mortem can be difficult for a woman to accept and absorb if there are issues about her anatomy and the possibility of conceiving and bearing to full term in a normal way. Would Mr. Thompson comment on the sort of follow-up needed from various specialists, that is not available in Ireland, and the possibility of having a post mortem on the foetus to advise for the future reproductive health of the woman?

Mr. Peter Thompson

The post mortem provides her with two opportunities. People often want a reason why something has happened. This gives an opportunity to close that chapter and allow people to move on. That is very important. Information can be difficult to hear sometimes but often it is better to have the information. The second point is that if a woman hears this story, and how bad it is, it is quite distressing because she has lost her baby but she wants to know whether it is going to happen again. We might be able to do the post mortem and say there is a 1:1000 chance this will happen again or we might find other differences in the baby as well. That means that it would appear the baby has a syndrome and that syndrome has a higher recurrence risk, a 1:4 chance. People will view those two facts very differently and can make decisions about their future reproductive life in the knowledge of what is there. In the service here this is a time when ultrasound scanning could be directed at a much higher risk group.

I thank Mr. Thompson for his very detailed and useful presentation. My first question, about the dangers of a strict definition of lethal abnormality, has been partly answered but could Mr. Thompson expand a bit on why the flexibility is important in terms of deferring to medical professions and say how that works in practice? If the legislation is more flexible are there standard guidelines that the medical profession would work from or would it depend on the doctor or consultant a woman is assigned to?

Mr. Thompson mentioned in his presentation that when a woman is beyond 24 weeks' gestation a team of hospital managers, two clinicians, a neonatologist and a midwife meet to assess whether to perform the termination after 24 weeks. Could he comment on the rate of abortions in these cases and if any are declined, why?

My third question is about an issue Mr. Thompson said he did not want to speak on. I would like him to comment on it but if he does not want to that is fair enough. It is ground D, when continuance of the pregnancy would have a harmful impact on the other children of the woman. We have not discussed that very much, apart from the socio-economic grounds. I do not know whether it would fall under that heading. Could Mr. Thompson expand a bit on that and how we would encompass that in our legislation? How is it assessed, is it based on the word of the woman saying her family would be negatively affected? It would be great if Mr. Thompson could walk us through that.

Mr. Peter Thompson

To start with the last question, it would be safe to say that many clinicians in the UK do not understand that they can use more than one clause. In the UK, two people have to fill out a form to say this woman meets the ground of one clause and most people were of the opinion that she must meet one but she can meet the grounds of several clauses. The figures I have given are for E alone, and with any other clause.

I was not here to discuss clauses C and D. I no longer do any gynaecology whatsoever, so I do not get involved in cases such as clauses C or D. Cases such as clause D obviously impact on the family if there is a baby with a significant congenital abnormality. In reality I believe that in almost every case where I agree to a termination for a significant foetal abnormality, I should probably also circle clause C, and if there are other children already present, I circle clause D. I do not believe how it cannot have an impact on them. I believe that more people should have multiple clauses circled but people tend not to do that. If they hit one hurdle then that is all people tend to be concerned about. If I scan a patient and the top of the baby's skull is not formed, the baby has anencephaly and the brain is being destroyed. I would not think about the social scenarios so much with regard to whether I needed to circle that clause.

I will now turn to the dangers of sticking to strict definitions. With regard to relative guidelines, there is no doubt that people do things differently in different units. Everybody has to find their own way but in the UK one has to find what one believes to be significant and serious reasons. Nobody can define what is right, but there has to be a standard deviation within which people fall. In the UK, if we see a woman who has asked for a termination of pregnancy for a foetal abnormality and if I believed that it did not fulfil clause A, then I am duty bound to find her a second opinion. The person who finds the second opinion may also say that he or she does not believe it either. That would be one scenario. I have come across cases where we have declined after 24 weeks. Reference was made to the group and the people who refused in those cases were the people who actually do the procedure, the clinicians. The others in the group had felt that the cases complied with the law and the people who performed the procedure did not.

In one situation, for example, which was a psychiatric case partly, the women said that she would kill herself if something did not happen. We did not feel that it had been explained enough or that enough detail had been gone into at that stage. We felt that we were only part way. One of the interesting things I learned from that case was that we were put under a lot of pressure to do this and then we said, "Are you going to sign one half of the form?", but nobody was happy to sign the form. They expected that we would. It is very important that it is the relevant specialty person who signs in this regard. If a doctor believes that a woman has a psychiatric illness and that is the reason she should have a termination of pregnancy, then psychiatrists need to be involved in it. They should be giving the opinions in those cases. I am not a psychiatrist. They should sign half of the form and then I can be involved in meeting the woman and make a decision based on what they say. If I agree, then I can sign the other half of the form. Other relevant specialties need to be involved in the process also.

I want to follow up on that point as it pertains to women in Ireland. Mr. Thompson has described a counselling system, options being discussed and detailed reports. In his response to Senator Ruane the witness spoke of situations where there is a difference of views among doctors. How much of that does a woman get if she travels from Ireland for a termination? Is any of this pre-decision making available to her with regard to options being discussed and having time to think about those options or do the doctors in the UK rely on this happening in Ireland?

Mr. Peter Thompson

We expect that they would have non-directive counselling in Ireland and when they come over we will discuss things with them. Often women are sent over for a second opinion. We re-scan, do everything from the beginning and re-counsel. It is difficult because just as we would do for a women from Birmingham or from Stoke, we do not agree to do a termination when we first meet them, but we impart some information and tell them to go away and think about it. The women from Ireland then have to find a local hotel in the UK or return to their community in Ireland. Most, however, tend to stay over in the UK, or Birmingham in our case. Most women from Ireland travelling for a termination used to go to Liverpool. Now it is London and some - fewer I believe - come to Birmingham. It is very difficult for these women. They certainly receive some counselling. I believe it is adequate.

I am more concerned that they do not receive the follow-up care that they should. This is not because the people in Ireland cannot, or do not, give it. If a woman has had a foeticide performed there should be some feedback afterwards. I ask patients if they have any questions about the procedure and how we got to that decision. It is very important that they say yes or no to that. If the woman is concerned about how she got to the decision then we need to explore it at that time.

When we consider the timeline, is Mr. Thompson aware of women who simply cannot come back for economic reasons and perhaps cannot afford to stay or cannot afford to return to the UK?

Mr. Peter Thompson

They have expressed to us about the costs, but once they are in the UK they tend to stay. There is, however, a constant pressure to keep the costs down for them. The woman's partner is often there too. One is aware of an external force that one probably should not be aware of.

Have I time for another question? It is about the definition issues, as the raised by the Chairman. There is no definition of substantial risk and in Britain there is the "in good faith" clause. In Mr. Thompson's' view, does this make it easier for medics to make decisions? Have there ever been court challenges on doctors' decisions or does that clause protect their medical judgment? I ask this in the context of Ireland's situation where the definition of the right to life of the unborn and the equal right to life of the mother causes real difficulties for medics' decisions as to when they are within the law or outside the law.

Mr. Peter Thompson

There have been court challenges. There was one that did not get to court where the Crown Prosecution Service examined a case of a termination of pregnancy because of a cleft lip.

There was considerable publicity about that at the time. It is easy to quote the very rare occasions when these things happen - they are very rare and that is the only one I can think of at present - but what I hope the committee would do is frame a law that would work 99.9% of the time and would be good for the women of this country in general, not concentrate on the 0.01%.

By and large, the witness would say that not defining "substantial", for example, is positive.

Mr. Peter Thompson

Yes. It allows a degree of flexibility. We are professionals and professionals in other disciplines make decisions with patients about resuscitation and non-resuscitation that could be argued about by other clinicians who would think that, perhaps, they had come to the wrong decision. It is not obstetricians alone who make these difficult decisions. I believe a degree of flexibility is required.

Senator Ned O'Sullivan has six minutes.

I had two questions but they have been anticipated almost exactly by Deputy Jan O'Sullivan and Senator Ruane. I have a general question which is not really part of Mr. Thompson's remit but he stated in reply to a previous question that women from less privileged backgrounds present later than the majority of women. Is there a programme in place in the UK to encourage earlier presentation? Is there anything in that regard that we could learn from in this country? Clearly, if women are presenting later they are possibly depriving themselves of choices which it might be too late to avail of.

Mr. Peter Thompson

The big changes in the UK over recent years are that we had targets which we had to reach for booking women, so having first contacts before 12 weeks of gestation was increased to having two contacts before then. The other key change was direct access to midwives. Initially, one had to get an appointment with one's family doctor and the family doctor would refer the woman to the midwife and-or the hospital. Now, there is direct access to the midwife so one almost misses out on the first part of the chain, which in some ways can be bureaucratic for many patients. The midwives will liaise with the GPs and the GPs can input from there, but it is not dependent on the GPs initiating the first contact. Women find it easier to contact midwives in those circumstances.

I thank Mr. Thompson for attending the meeting today. It is an interesting discussion. What happens if a woman or girl presents and has not made up her mind fully or has not been counselled previously as to whether she will or will not continue with the pregnancy? Is there a facility to counsel or assist in any way?

My other question relates to when there is a serious abnormality. Mr. Thompson mentioned something interesting, which we knew, regarding younger women and particular abnormalities, with the second baby having a difficulty as well. To what extent, if at all, can one assess the strength of character of the woman presenting in those circumstances? She is suddenly confronted with a serious issue. She is looking forward to giving birth and is full of expectation, but suddenly her hopes are dashed. What does Mr. Thompson do to assist her? Does she continue with her intention to have a termination or does she draw back from that? To what extent can Mr. Thompson tell whether she will be able to deal with the issue in her life ahead in the case of either the intervention or a normal birth?

Mr. Peter Thompson

With regard to counselling of women who are uncertain whether they wish to continue, is that in the context of a foetal abnormality?

Mr. Peter Thompson

That is relatively easy because it is a common scenario. That is one of the other reasons that gestational age limits are difficult. If there is a 24-week gestational age limit and the woman has an ultrasound scan at 20 weeks and two days, a week later she gets a second opinion in her local hospital and the following week she is seen by us for the first time, the gestational age is nearly 23 weeks already. If the limit is in one week we are going to say to the woman, "Now you must make up your mind and you have a couple of days in which to do it. If you do not make up your mind in that couple of days you are continuing with the pregnancy". It is much easier to say that there is time for the woman to come to the right decision. What people cannot do is flip between one decision and the other, and occasionally people do that. They say they do not want to have a termination but then follow up and say they want one. They come back and we discuss it and then they say they do not want it. It is difficult to make generalisations but often with people who are constantly changing their minds one ends up in the do no harm scenario and, by default, women may well carry on with the pregnancy. Where they keep changing their minds one does not want to do something that is irreversible.

We were given evidence to the effect that in quite a number of cases women change their minds. Can Mr. Thompson offer them any assistance at that stage in terms of counselling? For example, must they make up their own minds or, given her general demeanour, can he assess the strength or weakness of the woman in question as to whether she is taking the right course?

Mr. Peter Thompson

It would be difficult to say whether she is taking the right course because whatever course it is would be right for her. What we are much more concerned about is when people appear to be putting undue pressure on the woman. One of the reasons that we have a flexible time gap between diagnosis and when we would act is that it allows people to think. People have access to our telephone numbers and can speak to the midwives, who have been in the consultation as well and will also see the women again. Assessing somebody's strength of character is very difficult in this scenario, and passing judgment is difficult. However, we have difficulties when we feel that people are having undue pressure put on them by other members of the family either to continue or to end the pregnancy. That often becomes very obvious. Then we will see the patients apart from the other members of the family and discuss it with them in confidence.

Mr. Thompson mentioned young women, in particular, possibly having one or two children with serious disabilities or defects. To what extent is counselling available in the case of a woman or girl having a baby who proves eventually to have serious physical or mental or both sensory and physical difficulties? Does she receive counselling as to whether she has a pre-existing condition that might lead to a repeat of that?

Does she get adequate counselling and support in those circumstances to help her to make up her mind? Obviously there is a deep desire to have a normal baby. In the first instance, the woman may have had her baby with abnormalities in the knowledge that she wanted to have her baby anyway.

Mr. Peter Thompson

I would hope that they have adequate counselling. They will get counselling from their foetal medicine consultant. They will get counselling from the midwives because often the women will stay, we will leave the room and they will have a private conversation with their midwives. In addition, a subset of women will need to have an input from other specialists and sometimes those specialists are clinical geneticists. Then the clinical geneticist will see the woman on her own or with her partner and discuss the impact. Sometimes these things can have an impact on the children who are already born so the clinical geneticist can discuss those things with the woman and whomever. It is important that there is a care pathway that includes clinical geneticists as well.

I welcome Mr. Thompson here today. In his talk he spoke a lot about aborting babies because they had been diagnosed with a particular condition. I am very concerned that we would think it is okay to abort babies because they are going to be disabled. As Mr. Thompson has said, there is no way for a doctor to know how long these babies will live. Many families have been in contact with me to say that they have treasured the time that they got to spend with their babies even though it was not for a long period. Other families have told me that they were told that their babies would not live very long only to discover that the diagnosis was incorrect and the babies were born safely and enjoying life.

It is also worrying that in England and Wales something like Down's syndrome is seen as a reason to end a baby's life. We have all become familiar with the terrible statistics that nine out of every ten babies are aborted in these countries when there is a diagnosis of Down's syndrome. There is no reason the situation would be any different if abortion was introduced in Ireland. Does Mr. Thompson think that a diagnosis of Down's syndrome is something that should deprive a baby of his or her right to be born?

Mr. Peter Thompson

If the question is do I think that Down's syndrome or Trisomy 21 is a condition that fulfils the UK law of having a significant chance of severe handicap then I think it does. There are differences as well between babies with normal hearts who have Down's syndrome and babies with abnormal hearts who have Down's syndrome because the co-morbidities with Down's syndrome can greatly affect their outcomes.

One of the things that I did do was outline what happens in my unit in the UK. We also do a lot of the first trimester screening for the country whereby the blood tests are sent to our laboratory. I gave the committee some figures for affected pregnancies and the number of people who have terminations. As one can see, out of the 67 cases that were detected by screening 44 people opted to terminate their pregnancy. That is not 90%. That is a specific subgroup of people because between 30% and 40% of women have already opted out of this screening in the first place. Those women are women who would not want to contemplate having a termination due to Down's syndrome. This is a situation that is person-specific. What affects some people in some people's lives affects others differently.

Mr. Thompson's talk focused a lot on how babies who have been diagnosed with a condition are often aborted at various stages. As he said, the babies can be aborted at quite a late stage in pregnancy if a condition like Down's syndrome is diagnosed. I am worried by the fact that we are living in a world where something like Down's syndrome is seen as something that could mean a baby's life could be ended.

Doctors are trained to save lives and support tiny babies who are seriously ill. Does Mr. Thompson think that ending the life of a baby because he or she is sick goes completely against such training?

Mr. Peter Thompson

I think that it is a difficult scenario but it is part of the whole family and women's health scenario. I do not think that it is against the training of doctors, no.

Mr. Thompson, in one of his answers, talked about how we could consider a law that says abortion can be allowed where a baby is usually not going to survive. Does all of that boil down to a law where a group of people are allowed to decide whether a baby is allowed to live or not? This is completely the opposite to what we do here in Ireland, where doctors do their best to care for both mother and baby. If we repealed the eighth amendment and introduced a similar law to the one in the UK would it not fundamentally change what doctors do in Ireland? They would no longer care for two patients. Instead, they would be allowed to decide which sick baby to treat. Does Mr. Thompson think that we would then treat sick babies with a real lack of care and compassion?

Mr. Peter Thompson

I suppose the question is do I treat people with a lack of care and compassion and my answer would have to be no, I do not.

Mr. Thompson has mentioned in the background note in his statement that he supplied to the committee that he worked as a lecturer at the Royal Free Hospital.

Mr. Peter Thompson

Yes.

I am sure that when he was a lecturer he lectured young male and female students. What kind of lectures did he give? A lecturer can influence young people at an early stage. In his lectures did he say "Yes" or "No" or how did he guide his students?

Mr. Peter Thompson

Is the Deputy talking about guiding people in life in general, in obstetrics or about abortion?

My problem at the moment is that I do not want to repeal the eighth amendment. I am fully sure, having listened to Mr. Thompson talk, that he wants to repeal the eighth amendment.

Mr. Thompson is not here to comment on the eighth amendment. He is here to give us medical evidence.

Mr. Peter Thompson

Yes.

Mr. Thompson's introduction and everything that he has said seems to indicate that he favours repealing the eighth amendment.

We asked Mr. Thompson to come here to give us evidence on the foetal abnormality area. I do not think we require him to answer questions about our laws here unless he feels he wants to.

Mr. Peter Thompson

I do believe in the system that is present in the UK at the moment. Whether the Republic chooses to move down the road to a different system I acknowledge is its position completely and not for me to decide on in way, shape or form. However, I am happy to come here and discuss what the English experience is of working under a set of laws where the termination of pregnancy is available to women for babies with a significant abnormality.

My biggest fear is that back in 2016 there was over 190,000 abortions in England and Wales. Does Mr. Thompson think that number is very high?

Mr. Peter Thompson

Just over 3,000 abortions were performed because of a serious abnormality.

Does Mr. Thompson think 190,000 abortions a year in England and Wales is very high?

Mr. Peter Thompson

I am here to discuss babies that have had a termination of pregnancy, and how the termination of pregnancy works under clause E which relates to the 3,000 figure, which is a very small percentage of the 190,000 cases.

Mr. Thompson said a small percentage but I think even one abortion is a lot. I thank him for his answers.

I call Deputy Catherine Murphy and she has six minutes.

I thank Mr. Thompson for his presentation. I would like to acknowledge the fact that the legal and health care systems in the UK cater for a significant number of Irish women, and has done so for decades. Given our experience with mother and baby homes and Magdalen laundries, we are not in a position to be shouting from the rooftop in terms of how women have been treated in this country.

I want to ask Mr. Thompson about future proofing.

I take the point Mr. Thompson has made in respect of being overly specific about conditions. Obviously things have changed from a socioeconomic point of view. Very often people are delaying pregnancies and are availing of assisted reproduction. Sometimes there are twins or triplets in a multiple pregnancy. What impact has that had? Mr. Thompson made a point on a co-twin benefitting from the procedure. I presume that would happen in a situation where neither twin would be born alive without that intervention. In the area of future-proofing legislation, in Mr. Thompson's experience are there aspects of law which we must consider in that regard? The current situation is that there is an equal right to life. That right would probably extend to a situation wherein there were twins, neither of whom would survive without intervention. I am trying to think about this from a legal perspective.

Mr. Peter Thompson

Selective reduction is covered by the same clauses, however there is a subsection on the data collection form which asks whether an individual case was a selective reduction. The problem is that selective reduction comes with a risk. When one performs a selective reduction, it can cause the whole pregnancy to miscarry. One ends up having a discussion with the woman on which option presents the lower risk. In a case where there is a baby who is very unlikely to survive and another who seems to be completely normal, and where it is unlikely that either will be born alive if the pregnancy is continued, a selective reduction could decrease the chance of the normal baby dying. However, there will be as much as a 15% risk of miscarriage of the normal baby at the time the selective reduction is carried out.

If people are having pregnancies later, is it likely that more people will present with a need for------

Mr. Peter Thompson

Probably not. It becomes more and more difficult to carry out selective reductions later on. A high proportion of those pregnancies where a need is seen are also IVF pregnancies.

On the 20-week scan that is offered to every pregnant woman, does Mr. Thompson know what is the take-up rate?

Mr. Peter Thompson

It is almost 100%. Very few people decline it, although many people attend with the impression that the scan is for the purpose of seeing the baby. They are told beforehand that the purpose of the scan is to check on the baby's growth and the fluid around it and to see if the baby has any structural differences. It is difficult to know whether everybody understands that.

On the categories laid out in the legislation, categories A to E, in hindsight, if the legislation was being written now, does Mr. Thompson think it would be written in the same way? Does Mr. Thompson have any insights on aspects of the legislation which perhaps did not stand the test of time, for want of a better word?

Mr. Peter Thompson

The first iteration of this, in the Abortion Act 1967, used the term "viability". That was then changed in 1990. It then effectively said that babies at more than 28 weeks' gestation were viable, but it did not say that babies under that limit were not. That became an issue as survival rates for babies increased as time passed by. It became more about a specific gestational age than about viability. That is how it has changed. There have been several attempts to change it again through the UK Parliament, as I am sure the Deputy is aware, but none have been successful or supported.

I thank Mr. Thompson.

Approximately how many abortions did Mr. Thompson carry out under clauses C and D in the days when he practiced gynaecology, as he put it?

Mr. Peter Thompson

I could not say.

Will Mr. Thompson please try to estimate?

Mr. Peter Thompson

No.

The witness does not have to answer.

If the Chair will excuse me, I know the rules. I have asked my question and got my answer. Could Mr. Thompson estimate approximately how many abortions he has carried out under clause E?

Mr. Peter Thompson

I really would not be able to say. It is a smallish number. I do not know what the Senator would consider small, but-----

What would Mr. Thompson consider a small number?

On a point of order Chair, may I ask Senator Mullen to justify his line of questioning before he proceeds with it? Mr. Thompson was not brought here to have his own career scrutinised. He was brought here to give expert technical and medical evidence.

Senator Mullen may continue.

I thank the Chair. I was fascinated by what Mr. Thompson had to say about seeking to distinguish between those children with Down's syndrome with normal hearts, as he put it, and those with abnormal hearts. May I tell him something about children with Down's syndrome and their hearts as we experience it in Ireland? Children with Down's syndrome generally have very big hearts. There are thousands and thousands of people in Ireland who will tell Mr. Thompson about the love those children have brought into their lives. They would tell him about how unexpected the outcome was in many cases and about how what seemed like a disaster when receiving the news turned out to be a situation which brought untold love into the house. They would tell him how, far from causing mental health difficulties, the situation brought out the best in people as they had to discover and develop their caring sides. I remember a conversation I had with one very senior politician, who is still serving. He said that the child in his family who had Down's syndrome was the only one who really saw them all as equal and did not care about any of their achievements. The child did not compare any of them with one other and just loved them all the same.

Does Mr. Thompson accept that thousands of people in Ireland, who are listening to these proceedings or who will hear about his words in the coming days, will be chilled to the marrow? Does he accept that there are people who see that there are two lives to be cherished and protected in these situations? Does he accept that there are those who would be horrified by the way Mr. Thompson talks about the paralysing of the child, or the foetus to use the clinical term, that he carries out as part of the foeticide procedure, or the way he suggests that the odd story of babies with cleft lips being aborted is something we should disregard, as though abortion on such a trivial ground was just a small thing to be disregarded, a mere medical detail? Does he accept that he has an entirely different world view on this issue, perhaps from that of thousands of people in his own country but certainly from that of those who see two lives to be protected? Perhaps the fact that he cannot even estimate the number of abortions he has carried out highlights that point.

We will allow the witness to respond.

Mr. Peter Thompson

I accept that I have differing opinions on many aspects of life, not just this one, from those of other people. I also accept there are many people who have children with Down's syndrome who have brought much joy into their lives. I do not believe that all children with Down's syndrome should be terminated. I do believe that women should have choices available to them in cases of serious and significant abnormalities.

However, Mr. Thompson said that the foetus does not have rights in the UK. He does not seem to have a problem with that.

Mr. Peter Thompson

That is the case in law. I was just stating a fact.

Does Mr. Thompson have any ethical problem with that law? He seems to be happy to act under it.

The witness does not have to comment on that.

He does not but I am still entitled to ask the question.

I interject with many people on this committee.

We can talk about that again.

No. Excuse me. Will Mr. Thompson please go ahead?

Mr. Peter Thompson

I am sorry.

I put it to the witness that he does not seem to have any ethical problem with the state of the law. He seems to be quite happy to act under it. May I put it another way?

I suggest that Mr. Thompson has become desensitised to the humanity of these unborn children as a result of complying with procedures, including late-term abortions.

Mr. Peter Thompson

I disagree.

Mr. Thompson adduced evidence regarding marital breakdown rates and the pressure involved and specifically mentioned trisomy 21, which is Down's syndrome. Is he not giving that evidence in order to make out a case that such children are more of a burden and, therefore, to somehow sanitise abortion on those grounds?

There should only be one conversation in the room at any time.

In our culture, there are conventions on the rights of people with disabilities. Ireland has far more to do in that regard and many are concerned enough is not being done. However, disability is here being presented as a ground for abortion. Clearly, such people must be second-class citizens. Does it not make a nonsense of having a convention on the rights of those with disabilities if disability is a special ground for abortion in the witness's country and many others?

Mr. Peter Thompson

I brought up the concept of marital breakdown in certain conditions, as the Senator said. I did so in response to a question I was asked. Apart from that, I do not wish to respond. I was asked to come here to explain how the United Kingdom system works and how Irish women access it and that is what I am trying to do.

I am trying to bring out how the United Kingdom system works and the impact it has on the medical profession, as well as on unborn children, of which everybody is aware.

I wish to ask Mr. Thompson about foetal pain. He referenced the document from the Royal College which suggests it is less likely that there is foetal pain. It does not use the language of certainty. If there is a possibility of foetal pain, what would be the consequences of a precautionary use of anaesthetic, in particular in late-term abortions?

After 24 weeks, approximately what size is an unborn baby? I am sure it varies but can Mr. Thompson give us a sense of the dimensions of an unborn baby at 24 weeks' gestation?

Mr. Peter Thompson

As in-----

Mr Thompson may use his hands to indicate if he wishes or he can tell us in inches or centimetres what size a baby is. Many people discuss this issue as though it is mathematics but there are real-----

Senator Mullen has the floor. I ask for quietness in the room.

Mr. Peter Thompson

Approximately this size.

I ask the witness to demonstrate to those present and the television cameras.

(Interruptions).

The witness may answer the question in whatever manner he wishes.

Mr. Peter Thompson

I am uncertain as to the exact number of centimetres a 24-week foetus would measure. If I were to say it is too small or otherwise, I might be misleading the committee.

Mr. Thompson may communicate that to the committee if he has access to such information in order that he is happy he is providing accurate measurements.

Mr. Peter Thompson

The information will be easy to access and I will do so.

I thank the witness.

As Mr. Thompson said, he is not an expert on foetal pain. He is not certain enough of the dimensions of a 24-week-old foetus to be able to guide the committee in-----

He is an expert.

Yet he put them through his hands, if I can use the expression. I am trying to establish whether, in the context of foetal pain, he can be certain about that either.

He is a medical expert.

He said he is not an expert on foetal pain. When Mr. Thompson carries out an ultrasound-guided abortion, what does he see? I have never seen such a thing. When he gives an injection, does the unborn move in any way? Is that indicative of feeling or any kind of awareness? Is it merely the nervous system? Can he give us an image of the procedure in that regard?

Mr. Peter Thompson

Babies move. I refer to what the Royal College said. Whether or not reflex movements are associated with pain depends on when the cortex forms. Babies may move when any invasive procedure is carried out, whether that be to tap a baby's pleural effusion or to perform a foeticide.

Lest the Royal College be wrong, what are the consequences of precautionary pain relief? The language the college uses is far from certain.

Mr. Peter Thompson

The Royal College is addressing the issue in the broadest concept whereby if one uses drugs in general, there are always risks to the mother as well as the foetus. It depends on what drugs are used. People often-----

I have to sum up the session.

I am finished. In the words of the late Spike Milligan,------

Senator has had more than double his allotted time.

-----there is no Queen's counsel to take their brief in any event. I thank the witness for answering my questions.

Before the Chair moves on, I wish to place a point of clarification on the record. Senator Mullen said that Mr. Thompson has come here to make a case. Mr. Thompson came to give evidence, not to make any case. Perhaps I misheard Senator Mullen but that needs to be clarified.

I am happy to accept that clarification. Not much rests on it but I am happy to accept the clarification that Mr. Thompson came to give evidence. It was very illuminating evidence.

I thank the witness for appearing before the committee. He has provided answers to many of my questions. An Irish clinician who has dealt with women who travelled to the United Kingdom for abortions appeared before the committee. For legal reasons, such doctors cannot refer the medical files of such women to a doctor in the United Kingdom. That may give rise to difficulty in the case, for example, of a woman who is bipolar or on anti-psychotic medication. What is Mr. Thompson's professional expert view on the difficulties for a doctor in the United Kingdom in treating an Irish woman whose doctor could not refer the medical file and who may not bring or relay that critical information on her condition to clinicians in the United Kingdom? I presume such information would have a huge impact on how she would be treated, dealt with and supported in the United Kingdom should she need a termination, such as in the case of a fatal foetal abnormality. What problems does that pose for doctors in the United Kingdom? The committee has heard from doctors working in Ireland who encounter a legal obstacle to referring medical files to treating doctors in the United Kingdom.

Mr. Peter Thompson

One of the problems relates to being able to know how people are behaving. As I said, it is difficult to have an insight into how a person is behaving if he or she has a significant mental health disorder that nobody is divulging or can divulge. That can put us in difficulties. If a woman has a significant health problem, that can put us in other difficulties and the woman in danger. When under stress, people often do not reveal all of the issues they wish to communicate and do not tell us everything. Sometimes I forget some of my health problems when asked about them. It is quite difficult to go through those things. Such people are in very stressful situations and I sometimes think we give them sub-optimal treatment because we do not have all the information we should.

The legal implications in Ireland regarding referring medical files that prevent doctors being able to give the best medical information to a treating doctor in the United Kingdom for a woman who chooses------

Mr. Peter Thompson

It potentially puts the woman at risk.

It puts the woman at risk. I thank the witness.

I thank the witness for his presentation. Most of the questions I intended to put have already been asked. On page 6 of his statement, Mr. Thompson mentioned that he would expect the number of requests for termination of pregnancies in cases of diagnosis of Down's syndrome to be high and that that would not be representative of the population.

What does he mean by that?

Mr. Peter Thompson

There is the general population. How screening works is explained properly to everybody. We are just talking about screening for chromosomal abnormalities. At this point, between 30% and 40% will say they are not interested and opt out immediately.

The second step, so to speak, is that a risk is ascertained. When people are informed of the risk and despite the first risk, some people will actually say they had the test because they just wanted it to be low in order to have some good news and reassure them. Other people will view the risk they get as actually not very high anyway. We have a cut-off risk of one in 150 at which we will offer invasive prenatal diagnosis. Some people might view one in 140, for example, as a low risk and then not go on to have invasive prenatal diagnosis.

Those women who go on to have invasive prenatal diagnosis, which carries a risk of miscarriage meaning that for the first time they are doing something that carries a risk of miscarriage, are doing it for three main reasons: it would impact on how the baby would be managed after birth; some people feel that once they have been given this higher risk, they just have to know; and other people do so because they are going to act on the result. A high proportion of people in the end, therefore, act on the result because they have been through several screening processes beforehand whereas people who would not act on that result actually cannot get that far. I am not sure if I explained that properly to the Deputy.

No. I am afraid Mr. Thompson lost me there.

Mr. Peter Thompson

I could start with 100 women, all of whom have the same chance of having a baby with Down's syndrome. Of those, 40 just leave the room immediately and say, "I don't want any testing". Of the remaining 60, ten come back as high risk. Those women are all spoken to and offered an invasive test. Seven of those might take it up and three will decline it because they will say, "Actually, I was going down this process, but now I have to take a risk and I'm not going to take a risk over my baby". If any of the seven who have the invasive test out of the original 100 are identified as having a baby with Down's syndrome, a high proportion are likely to act on that information. It depends on what proportion one takes. Is it a percentage of the people who have the amniocentesis or is it a percentage of the general population? Therefore, that group is not representative of the general population.

Therefore page 6 shows the people who have come in and looked for the testing.

Mr. Peter Thompson

Yes.

Is that figure reflective of the affected pregnancies, the 76?

Mr. Peter Thompson

The affected pregnancies are all pregnancies; it is the general population. The figure of 67 is those detected by screening.

All right. Of them, 44 chose medical terminations.

Mr. Peter Thompson

Yes.

There were six spontaneous terminations, miscarriages.

Mr. Peter Thompson

Those six could be from any group.

Absolutely. There were 13 confirmed live births.

Mr. Peter Thompson

Yes.

I just wanted to understand how that was worked out.

I call Senator Gavan. If anyone else wants to come in, they need to indicate; otherwise, Senator Gavan is last.

I thank Mr. Thompson for his presentation. The committee has received consistently high-quality presentations. I was struck by the large number of facts and statistics. It gives a very good insight into practice in Britain. I thank him for that.

I am not sure if Mr. Thompson can comment on this, but I will ask anyway. We have had medical professionals from Ireland and Britain, people whose job is to care for women and their babies. They have been consistent - Mr. Thompson has been just as consistent today - in highlighting that we should trust medical professionals. The witnesses from Ireland, including the masters from the Rotunda Hospital and the National Maternity Hospital, Holles Street, have been consistent in saying that the current laws are restrictive and a danger to women's health. Why does Mr. Thompson believe that the medical professionals, the people whose jobs are to care for our loved ones, are so consistent in this message that the current set-up in Ireland does not work for women?

Mr. Peter Thompson

I know about two aspects of the current set-up in Ireland. One aspect is from personal experience and women coming over to us. The other is from my discussions with some of my colleagues here and how they have difficulty in interpreting the equivalent of our clause A when doing a termination of pregnancy when a woman's life is at risk and how they feel that there is great danger. The one thing that is similar is that it is a criminal offence in both countries at the moment if someone does not fulfil the law. As I understand it, the difference is that here it is also a criminal offence for the woman, whereas in the UK it is just the doctor who commits the criminal offence.

It is likely that it will be decriminalised in the UK. Certainly the Royal College of Obstetricians and Gynaecologists has suggested it should be monitored, as other aspects of medicine are, by the General Medical Council. A similar thing would be sensible here.

Most of the questions have already been asked. I thank Mr. Thompson for attending to give evidence to the committee. During the course of the committee's work, I have been contacted by people on both sides of the debate and people in the middle of the debate. Clearly, we do not have consensus in the country as to how we should proceed. While I have seen no medical evidence to support this, it has been suggested that somehow having a termination puts a woman at greater risk of breast cancer. I do not know if any other members of the committee have been presented with this as though it is a fact. I cannot find any medical evidence to that effect. Has Mr. Thompson come across that? I am conscious that as a Member of Parliament I am here to represent my constituency and all the different views and ask the questions that have been asked of me. I am just asking that question as it has been presented to me.

If a child is born with a very severe or serious abnormality - whatever term one wants to use - does the child then experience pain having been delivered? Is it Mr. Thompson's medical view that it would be more humane not to deliver a child with serious difficulties or severe abnormalities?

Mr. Peter Thompson

There is more evidence on how the cortex develops post-delivery and how pain is perceived by a pre-term baby than there is on the foetus, and more conclusive evidence certainly. The royal college document states that parallels should not be drawn between in utero and ex utero even if it is the same gestation.

Regarding the link between termination of pregnancy and breast cancer, I think there is a stronger link with pregnancy, but I am not aware of it particularly being termination of pregnancy. I would be more than happy to check that for the Deputy and feed it back to the committee.

I am not sure if Mr. Thompson is familiar with the report of the Citizens' Assembly or if he has had an opportunity to read it. The citizens voted on a variety of reasons.

Reason 11 was that the unborn child has a significant foetal abnormality that is likely to result in death before or shortly after birth. The Citizens' Assembly favoured applying this only up to 22 weeks of gestation. This is an issue that the committee has to grapple with and I appreciate that Dr. Thompson has a different legal framework. We are not commenting on that framework, good, bad or indifferent, but we must grapple with this issue. Could Mr. Thompson comment on the workability of this? Is it feasible?

Mr. Peter Thompson

It is certainly feasible that some women would undergo a termination of pregnancy on those grounds but if one were to rely on a 20-week scan, then a large proportion of women would not do so. For a certain number of women who get a diagnosis at 20 weeks, there would be a rush to make a decision in the next two weeks. The committee should bear in mind that if Ireland were to go down a similar path to the United Kingdom, parents would probably not get a confirmatory discussion until another week after the scan, leaving them feeling that if they do not make a decision within the next week, they may not get the opportunity to make a decision at all. It is for the committee to decide whether that might force women one way or the other.

We have not yet had much discussion at this committee about term limits. Is talk of term limits in that way unhelpful to medical practitioners or by enshrining that in legislation?

Mr. Peter Thompson

The 22 weeks?

Not necessarily 22 weeks.

Mr. Peter Thompson

Any number of weeks?

Mr. Peter Thompson

I think it is unhelpful in the concept of things like microcephaly, which cannot be diagnosed at that point. It obviously depends on what Ireland as a country wants to achieve with regards to a percentage that will be detected and which abnormalities will be detected.

I thank Dr. Thompson very much for his evidence here today, for carefully answering all of our questions and for travelling over to us. We really appreciate his attendance.

We will take a break for a few minutes. I think we would rather continue and finish earlier today rather than taking a long break at this point, so we will just take five minutes for now.

Sitting suspended at 3.53 p.m. and resumed at 4.03 p.m.