I thank the Minister of State at the Department of Health and Children, Deputy Moffatt, for coming into the House this evening. I hope he will sympathise with my request. I ask that the Minister for Health and Children, Deputy Cowen, ensure that the ethical code of any public hospital does not prevent patients having any treatment which is legal in this country.
The Minister of State at the Department of Health and Children, Deputy Moffatt, would understand why we are so justifiably proud of our maternal mortality figures. In Ireland few women die during pregnancy, childbirth or the post partum period but only one generation ago the situation was not so good. Until the late 1960s many women died from causes related to childbirth, many of them were older women who had large families. In some cases they already suffered from chronic illnesses, such as kidney disease and heart disease.
It is not just the advances in medicine which have brought about this welcome change. Other factors were important too. With the arrival of contraception in this country the average size of families fell from over four to about two in one generation. This startling change has not been seen in any other country. It shows that there was a need for contraception within the population which had not been supplied. In particular, the number of very large families decreased dramatically and nowadays older women who are having children are usually in excellent health. In many cases they have delayed having families.
Initially only the contraceptive pill, which at that time was a high dose oestrogen pill, was available. Indeed, the Minister may remember that it used to be referred to as a cycle regulator before even that could be prescribed here as a contraceptive. This pill was one of the least suitable forms of contraception for those older women who may have most needed contraception. Many of them would have benefited from the availability of tubal ligation but this operation, while legal in this country, was not available in many public hospitals because of objections made by people who worked there, who were involved in the management of the hospital or who were the owners of the hospital.
Over the years other methods of contraception have become widely available and tubal ligation is available in most public hospitals where gynaecology or obstetrics are carried out. Medical practitioners and nurses who do not sympathise with such treatment of course are not involved in providing it. If, however, a patient, in consultation with her doctor, decides that this is the most suitable form of family planning for her, it is generally available.
Many years ago it was suggested that our high hysterectomy rate was due to the lack of availability of tubal ligation and that some doctors were forced to carry out hysterectomies, despite the fact that the lesser operation of tubal ligation involved far fewer complications and would have been more suitable in these cases. This may have happened with older patients with large families in particular.
It is important to point out that, as the Minister will be aware, a hysterectomy is an operation with its own risks, both of mortality and morbidity, and should not be carried out unless it is absolutely necessary for medical reasons. Certainly it should not be carried out for family planning reasons alone.
As the Minister will be aware, there have been problems with the practice of obstetrics in the North Eastern Health Board region. One doctor has been reported to the Medical Council and suspended for some months because of the high rate of caesarean section hysterectomies in his practice. An investigation has been carried out at the behest of the North-Eastern Health Board by some members of the Institute of Obstetrics and Gynaecology. Their report apparently suggests, according to the Irish Medical Times of Tuesday, May 4 1999, that “the ethical code of Our Lady of Lourdes Hospital, Drogheda, which forbids sterilisation as a means of contraception may have contributed to the high rate of caesarean hysterectomy by a consultant there”.
When the Medical Missionaries of Mary sold the hospital to the North-Eastern Health Board they insisted that the code of ethics of the hospital should include a clause which states: "Sterilisation, the exclusive purpose of which is contraceptive, is not permitted." The report by the review group of the Institute of Obstetricians and Gynaecologists, again according to the Irish Medical Times, suggests “the code of ethics of Our Lady of Lourdes Hospital in Drogheda should be changed to recognise the responsibility of a State hospital to provide legal methods of family planning and sterilisation”. As well as the removal of the relevant clause, it has called for the insertion of two new clauses into the hospital's code of ethics: first, that a patient has the right to decide, with advice from a doctor, which methods of family planning, including operations to sterilise, should be availed of as long as they are legal; and second, recognition that some doctors for reasons of conscience may not wish to take part in some treatments and have the right to have this respected. I fully support the review group's recommendations and would ask the Minister to rectify the situation at the hospital immediately.
If the doctor involved felt forced to perform caesarean hysterectomies because he had great difficulty in sterilising patients at the hospital due to the ethical code, he was put in an intolerable position and could not make what he may have felt were the best clinical judgments. Neither hospital management nor hospital ethics committees have any legal right to interfere with decisions made by a patient with his or her doctor and this should be made plain to all concerned.
Minister of State at the Department of Health and Children (Dr. Moffatt): I am glad to have the opportunity, presented by Senator Henry, to speak on this important issue. It is the role of the Minister for Health and Children to ensure a balanced delivery of health care services of all types. This requires the Minister to ensure that the principles of equity of access to care, quality of service to the patient and accountability to the public as a whole are observed at all times. The function of the Minister lies in ensuring that the environment in which medical care is delivered meets the test of these standards.
Our approach to medical care has long been founded on the importance of the doctor/patient relationship. This privileged relationship has, rightly in my view, been protected by practitioners and patients alike. The quality of our health care system has depended to a considerable degree on this attitude by doctors, nurses and other health care professionals. At the point of treatment, each patient must be treated as an individual case.
The obligation of the Minister for Health and Children is to ensure that resources are available to allow any procedure which is legal in this country to be carried out. By this, I mean resources in the largest sense – money, facilities, people and skills. This obligation must, of course, take account of limiting factors which require us to prioritise services, based, where possible, on objective assessment of clinical need.
We have ensured traditionally that general practitioners can refer patients to the hospital which they feel would offer the service most suited to their patients' needs. This approach allows clinicians and patients to make decisions based on quality of care, convenience or any other factor which may be important to them. However, another right which has long been recognised in our health service is the right of staff with conscientious objections to participating in any particular treatment to decline to do so. I am aware that the current Medical Council and Bord Altranais guidelines provide for cases of conscientious objection by staff. Equally, the Medical Council is specific about the responsibility to patients which must be observed by clinicians in these circumstances. Specifically, section B, 2.1 (1998) of the Medical Council Guidelines for doctors provides: "if they wish to withdraw their services they must inform the patient and allow sufficient time for alternative medical care to be sought, during which time clinical continuity must be maintained". I would expect that in circumstances where a staff member felt obliged to withdraw from participating in any procedure, the health agency or clinician involved, as appropriate, would refer the patient to an alternative carer.
Some of these issues have arisen in the context of a recent case involving a consultant in the North-Eastern Health Board. I do not wish to say anything further on this case, other than to note that the independent report on the consultant's practice has been referred by the North Eastern Health Board to the Medical Council. I will take the Senator's comments on board.