Symphysiotomy Payment Scheme: Statements (Resumed)

A systematic review and meta-analysis study published in the British Journal of Obstetrics and Gynaecology as recently as April 2016 concluded that there was no difference in key outcomes of maternal and perinatal mortality with symphysiotomy when compared with caesarean section. One of the principal reasons for use of symphysiotomy in rare circumstances was the dangers associated with caesarean section, which were very real in the 1950s and 1960s. This is supported by data from Irish hospitals which shows the rates of maternal and infant mortality were higher for caesarean section than for symphysiotomy.

In summary, it is important to note that Irish and international studies indicate that symphysiotomy is not a banned procedure but has a place in obstetrics in certain limited circumstances. For example, it may still be used in the western world in the delivery of a trapped head in breech delivery, or in emergency obstetric situations. The health of women affected by symphysiotomy has continued to be a priority. Medical services, including medical cards, are facilitated for the women by HSE-nominated symphysiotomy liaison officers based around the country, whether or not a woman has availed of the scheme.

In regard to human rights issues, one of the advocacy groups made representations to the UN Committee on Human Rights concerning symphysiotomy in July 2014. This year, submissions were also made to the UN Committee on the Elimination of Discrimination against Women. Ireland takes its membership of international organisations extremely seriously and is committed to human rights, which is why we always engage with these processes in a meaningful way, through providing information and updates, responding to recommendations and attending reviews held by these organisations. While the Government notes the comments made in 2014 by the UN Committee on Human Rights on symphysiotomy, the Government believes that there has been a comprehensive response to symphysiotomy with the provision of the following: the independent ex gratia scheme; the comprehensive independent reports on symphysiotomy, which included national consultation with the women; and the ongoing provision of medical services by the HSE.

I would urge anyone who wishes to get a fair and balanced view on the issue of symphysiotomy to read Judge Harding Clark's report. She was unfettered by Government in completing her work. She used her judicial skills and experience, and the skills of her clinical team, to examine all aspects of symphysiotomy and review the evidence collected during the two years of her work.

In conclusion, the brief given to Judge Harding Clark in November 2014 was not an easy one. At that time the advice to the Department of Health was that many women would face an uphill struggle in proving their claims in the courts. Each woman would face an uncertain outcome, as each case would be adjudicated by the courts on its individual merits. We now know that this is true. For example, in one of the small number of cases that have gone through the courts, the judge in that case found that even though the woman had a symphysiotomy 12 days before her baby was born in 1963, this procedure was not a practice without justification at that time. In her independent report, Judge Harding Clark has set out in detail how assessments were made and confirms that she personally reviewed and assessed every woman’s case. Judge Clark has also provided a comprehensive overview of the historical and medical context of symphysiotomy.

The Government hopes the scheme has helped to bring closure to women who underwent surgical symphysiotomy and their families.

Before Senator Swanick makes his contribution, I welcome to the Gallery the former Cathaoirleach, Charlie McDonald, and his two lovely granddaughters who are visiting today. It is great to see Mr. McDonald back and respecting the House. I served with him for a while a long time ago.

I will start with the words of one survivor of symphysiotomy:

They gave me gas and air and an injection, and took me to another room, where they tied my legs up on each side. There were two nurses on each side of me. I saw this doctor at the end of my bed with a big, long silver thing. They made a hole in your private parts, and he inserted this silver thing up and cut the pubic bone and pushed it over to widen your pelvis for you to deliver your baby yourself.

Petrified and in agony, the woman in question had just been subjected to a symphysiotomy. For the five days following the procedure, the new mother was ordered to lie completely flat with a corset around her hips to give her pelvis a chance to heal. For days, she was unable to see her daughter in the special care unit because there was no lift. To use her words again:

I have arthritis in my hip and in the bottom of my spine. I walk with a limp. No one can help – there’s no way back. I wear pads the whole time, and have been since the age of 23.

Symphysiotomy, which was seldom used in the rest of Europe after the mid-20th century, was carried out on an estimated 1,500 women in Ireland between the 1940s and 1980s. Ireland was the only country in the world where these childbirth operations were carried out in preference to caesarean section. Many attribute this to religious ideology and doctors who believed in child bearing without limitation. Whatever the reasoning, the outcome for women has been lifelong disability, chronic pain, mental suffering and in some cases family breakdown.

In 2014, the United Nations Human Rights Committee found the following in respect of Ireland:

The State party should initiate a prompt, independent and thorough investigation into cases of symphysiotomy, prosecute and punish the perpetrators, including medical personnel, and provide an effective remedy to the survivors of symphysiotomy for the damage sustained, including fair and adequate compensation and rehabilitation, on an individualized basis. It should facilitate access to judicial remedies by victims opting for the ex-gratia scheme, including allowing a challenge to the sums offered to them under the scheme.

In that context, we have done some of what the committee asked and I hope the publication of Judge Maureen Harding Clark's report on the surgical symphysiotomy ex gratia payment scheme will bring some type of closure to the women who have been so badly affected by symphysiotomy. The historical indifference shown to survivors of symphysiotomy has meant some women still do not know exactly what procedures were performed on them without consent, resulting in some cases in them spending their entire adult lives in pain.

As a general practitioner, I swore the hippocratic oath. Historically taken by physicians, the oath is one of the most widely known of Greek medical texts. In its original form, it requires a new physician to swear by a number of healing gods to uphold specific ethical standards. It is considered a rite of passage for practitioners of medicine in many countries. While various modernised versions are often used nowadays, the message delivered is still the same - above all, do no harm. The medical practitioners who conducted the symphysiotomy procedure took the same oath but did not abide by it. I am glad this procedure plays no part in medicine in the 21st century.

The Fianna Fáil Party believes the scheme was a genuine attempt to bring a resolution to this matter. Many of the findings of the report make for very distressing reading. The practice of symphysiotomy had stopped in other countries many years before it ceased in Ireland. When it went wrong it caused many debilitating physical, psychological and emotional side effects and many women experienced medical problems for decades. I hope they will be able to access the treatment and supports they badly need. Unfortunately, four of the women affected passed away before the final report was published.

Thankfully, symphysiotomy is no longer an accepted practice in obstetrics. It is crucial that the medical profession learns lessons from the past. I sincerely hope the Institute of Obstetricians and Gynaecologists will study the report in detail.

I call Senator Conway-Walsh.

The Cathaoirleach has the wrong Senator.

My apologies. Senator Conway-Walsh normally sits in the seat occupied by Senator Devine. I should have known Senator Devine would speak given her background in nursing. We all have our shortcomings.

It was a senior moment on the part of the Cathaoirleach.

Is that a diagnosis?

Probably. Symphysiotomy, a word I have difficulty pronouncing, is a barbaric and medieval practice, which was carried out for many years in this State. It is a procedure that women were advised to undergo without knowledge of what it involved. Symphysiotomy is similar to the spatchcock cooking technique used in the preparation of birds. It involves the use of a chainsaw and was often practised without the consent of the women in question. Certainly, the women did not make informed decisions. While the procedure was abandoned by the rest of the western world before the turn of the 20th century, hundreds of cases were recorded in Ireland in the 20th century. I was not surprised to read that the latest recorded case took place as late as 2005, in other words, in the 21st century.

Survivors of symphysiotomy demanded a truth commission and their demand was eventually granted in the form of the review carried out by Judge Maureen Harding Clark. The judge delivered her opinion as judicial assessor on the surgical symphysiotomy payment scheme in November 2016. Judge Harding Clark was tasked with determining the legitimacy of claims made as best as the women's testimony and records available would allow and evaluating the extent of disability and discomfort inflicted by the procedure. She described the payment scheme as an ex gratia non-adversarial scheme under which survivors would be treated in a compassionate and generous manner. For many of the women, who are now elderly, frail and exhausted by the ongoing fight for truth and justice, Judge Harding Clark's report swept aside and demeaned their ongoing experience of ill health and disability. They correctly believed the report was a deliberate whitewash.

We have all been witness to the harrowing accounts given by the women affected by symphysiotomy over the years and the debilitating effects the procedure had throughout their lives. Senator Swanick cited the words of Annie, a woman in her late 60s who recalled vividly her account of the procedure which was carried out without her knowledge and consent. She recalled having her legs in the air, being taken to a different room and not knowing what was happening to her. She saw a "silver thing", colloquially referred to as "the chainsaw", which was inserted in and destroyed her body. Annie lives with the agony of the procedure which persists to this day.

In her report, Judge Harding Clark stated that 142 of the 183 women who were awarded higher payments were assessed as having suffered significant disability. However, she also stated that the majority of applicants made a good recovery. The Minister should tell this to Annie and her fellow survivors.

Judge Harding Clark's report was welcomed by the handful of obstetricians who hold steadfast to their practice and continue to defend the procedure. We must also remember that the hospital system was overseen by senior figures in the Catholic Church, who would have considered symphysiotomy a better outcome than an unholy caesarean section or the possibility that the woman would no longer be able to procreate.

Judge Harding Clark, who did not speak to all of the women concerned, further stated that symphysiotomy did not inevitably lead to lifelong pain or disability and patients did not age in a manner which was different from women who did not experience the procedure. How would a body respond to the trauma of symphysiotomy, a procedure in which a chainsaw is used and cartilage and ligaments split? It involves splitting open the woman and flattening her out almost in the manner of poultry being prepared for roasting. A body cannot heal or knit together uniformly after such a procedure. Such an out-of-kilter body would produce pain and other disability conditions throughout life, which would add to the emotional trauma the women in question continue to suffer.

The United Nations and the Irish Council for Civil Liberties called the use of this operation an assault. It was yet another assault on Irish women, another scandal perpetrated against women and girls, joining the revelations about the Magdalen Laundries, the deaths of children at mother and baby homes, sex abuse within the Catholic Church and the case of Savita Halappanavar who bled to death in hospital watched over by a medical team four years ago. A son of one of the survivors wrote recently to Deputy Caoimhghín Ó Caoláin about Judge Harding Clark's report. He wrote that a one-sided report that attempted to whitewash over this shameful episode in Irish medical history had compounded the traumatic stress of the women involved, rather than seeking the truth, which might have gone some way to helping his mother and the other women involved to come to terms with the consequences of their experiences. Judge Harding Clark has aggravated the butchering of the women concerned and undermined their experiences and trauma. Shame on her.

Contrary to the Minister's positive statement, the international community is dismayed by the report and our general approach to historical human rights violations. The Government ignored the United Nations Human Rights Committee's recommendations in 2014 relating to this scheme and ensuring there would be a proper inquiry. It has now been criticised by another UN body, the United Nations Committee on the Elimination of Discrimination against Women, which recently examined the issue and will be giving a judgment in the coming weeks. We do not seem to have learned from the past litany of horror and cruelty. The State continues to punish, harass, criticise and humiliate women for its failure in its duty of care to them and its own severe lack of compassion.

The Minister of State has outlined what symphysiotomy is and the differences between it and pubiotomy where a saw is used to cut through bone. One case was identified and can be shown to have occurred. Symphysiotomy involves cutting through the cartilage that joins the two bones and was a recognised procedure in the 1940s and 1950s. By the 1960s caesarean section had become a safer alternative. It is very upsetting to think the use of symphysiotomy was continued when there were safer alternatives which would not have led to many of the lifelong disabilities from which many of the women concerned - citizens - suffered. There is no question but that they did suffer, from urinary incontinence, pain while walking, bowel function disorder and their ability to undertake day-to-day duties and look after their families. Sometimes it led to marital disharmony and family break-up.

I am pleased that 399 women availed of the scheme. There was advice that they take the legal route and, as Minister at the time, I was concerned that many of them would find it difficult to find documentary evidence to present. I was concerned that they would find that notes had gone missing and that the clinicians who had carried out the procedure were no longer alive and that they would spend the last years of their lives building up legal bills without having a resolution. The scheme was developed to avoid this and ensure speedy compensation for those who had suffered throughout their lives and that they would not have to endure further worry and anxiety. One lady, whom I know but whose name I will not mention, openly told us that she had an open and shut case. Of all the times the operation could have been performed, it is incredible that it was performed after a baby had been born, but that was what happened and she and her legal team believed they had a clear case. The decision was appealed, however, and she woke up one night and realised she might lose her house. Thereafter she became a great supporter of the scheme.

There was a lot of misinformation. It was stated a person who did not like the award under the scheme had already waived her legal rights, but that was not he case. The legal route was always available to those who felt it was preferable. As the Minister said, a number of legal cases were taken and failed. No scheme is perfect, but I thank Professor Oonagh Walsh and Judge Yvonne Murphy for their work on it, as well as the patient folk who represented the women involved and the women themselves, many of whom I met. It is difficult for them to have closure, but I hope the scheme has brought some closure for them. I know that there is still criticism of it and that no amount of compensation can bring back the years in which they might otherwise have enjoyed full health, but I hope it vindicates them and makes them feel the State recognises that a wrong was done.

There is a time when a procedure is all that is available and one might call the removal of a leg "barbaric", but if it is the only surgical option, people understand it has to be done. The situation in this instance was different. The world had moved on, meaning that there were much safer ways of dealing with the issue, but certain clinicians, perhaps for religious reasons as other Senators have suggested, proceeded with this procedure rather than safer, more modern procedures. In my view, it was professional negligence, but I am glad that the Government developed the scheme and very proud to have been associated with it. I hope we have brought some sense of closure and recompense to console those who suffered in their later years.

I recognise the compassion the former Minister for Health, Senator Reilly, has consistently shown in this regard and the eloquent case he has made in defence of the redress scheme. I was involved in the design of the scheme on behalf of constituents of mine, with the Minister of State, Deputy Regina Doherty, and others. Senator Reilly has been a consistent supporter of the rights of the women involved.

I am no stranger to the issue of symphysiotomy with which I have been dealing for nigh on 15 years. I recall the very first meeting I attended in 2002, with former Deputy Arthur Morgan who had also expressed a huge interest in the issue, to educate myself about symphysiotomy and how it affected women. The meeting was hosted by the nascent survivors of symphysiotomy group which became known as SOS Limited and was supported by the excellent Patient Focus, with which the then Minister, now Senator Reilly, worked very closely on a range of initiatives to deal with this scar on our recent history. I was absolutely stunned and horrified by the testimony of women such as Olivia Kearney from County Louth who had been a victim of this mediaeval procedure and who, like hundreds of other women, had lived for decades with its consequences.

Olivia Kearney and our colleagues in Patient Focus and others have fought a dignified and respectful battle, often in hostile circumstances over the years, to deliver a scheme that works. I commend them for that.

I beg the Cathaoirleach's indulgence to pay tribute to a lady who passed away just over a week ago, Ms Elizabeth Moran, a survivor of the procedure. Her husband, Mr. Tommy Moran, at one point chaired the Survivors of Symphysiotomy Limited, SOS, group and worked very closely with me and others in the House and Members of the other House to try to address some of the wrongs that were done to his wife and to other women across the country. It is a deeply personal issue for me because while the procedure was discontinued in many hospitals across the State decades ago, and it was discontinued across the developed world decades ago, there still are records to prove that the procedure had taken place very recently in Our Lady of Lourdes Hospital in Drogheda, my home town hospital.

I have friends and neighbours, family friends and people who I care about, who have been affected by this procedure, so I took a deep personal interest in it. The previous Government, as Senator Reilly said, and as the Minister of State, Deputy Corcoran Kennedy, has said, took a deep personal interest. Not to make too political a point, we have had successive Ministers for Health, going back to Deputy Micheál Martin, former Deputy Mary Harney and others who have effectively ignored this issue. We attempted to challenge this head-on. When I was elected to the Dáil in 2011, I set myself the objective, through working closely with Senator Reilly and colleagues across the north east region, of having a full and detailed examination in the first instance of the reality of the practice of symphysiotomy in this country. We would then use that evidence base to work out a way whereby we could assist the hundreds of women who have survived that procedure and are affected by it, to take some kind of practical action that would acknowledge the hurt and pain that they experienced. We did all that. We commissioned the Walsh review. We commissioned the Judge Yvonne Murphy report, a comprehensive report into the practice, and ultimately we designed the Surgical Symphysiotomy Ex Gratia Payment Scheme that was expertly administered by the extremely well-respected and independently-minded judge, Judge Maureen Harding Clark.

Remarkably, practically at every turn, the respective judges, the Government, experts involved and in some cases we as individual public representatives were excoriated and were subjected to bizarre allegations of being responsible for a whitewash, a charge that was repeated in this House today. To quote a headline and very informed piece by Mr. Paul Cullen when he was writing in The Irish Times about symphysiotomy recently, the headline said it was the whitewash that never was. There was voluble and sometimes very hostile criticism of public representatives and NGOs, which wanted at all times to put the interests of the women affected first. When others in these Houses preferred to, as Senator Reilly suggested, encourage survivors to take their chances through an adversarial judicial system that in some cases had objectively very little chance of delivering for them, this was most unfortunate.

Objectively, the scheme has been a success. We all worked hard to develop a scheme that worked. It will not heal all of the hurt that has been experienced by the women involved and their families. There are still physical and emotional scars that people are living with to this day. I hope that the scheme that has provided payments to approximately 400 women has helped to some degree to right the wrong that the women have experienced. I am proud to call many of those women friends.

This island has many dark histories. The scandal of symphysiotomy has been a brutal and inhumane procedure and reality for some time for some women.

With respect, I think the Minister of State missed a certain 2012 study in her contribution that found that many of the victims and survivors of symphysiotomy said that the Catholic Church encouraged, if not insisted upon symphysiotomies. Other speakers have mentioned that was the case due to the preference of the church for symphysiotomy over caesarean sections and the moral diktat of the day gave women no bodily autonomy and saw them as mere vessels, regardless of the mutilation, health issues and unbearable pain that caused.

Senator Nash brought forward a Bill where we spoke about the exoneration and apology to gay men who were victims of criminalisation. I took the opportunity to talk about the impact of criminalisation for certain sections of society. I hope the reality of today's abortion laws, that similarly condemn women to sometimes devastating health problems, is not lost on the decision-makers here in both Houses. Women and the LGBT community share the most unfortunate commonality, the contemporary and historical criminalisation of their body and of their lives. The misogyny and deeply ingrained sense of prejudice faced by women since the foundation of this State will lead older women to a place where they will actively campaign and have been campaigning for bodily autonomy and a repeal of the eighth amendment.

After years of campaigning, in November 2012, the Surgical Symphysiotomy Payments Scheme was established and Judge Harding Clark, who set out the terms of reference for that scheme, has been said by survivor advocacy groups to be lacking in empathy in the application of the scheme. There can be little objection to what the State owes to these women. It should endeavour to do all it can to provide these women with comfort. Senator Reilly said in his contribution that his concern while Minister was that women who would pursue a legal route would not have access to certain documents. My understanding is that Judge Harding Clark requires records going back over 50 years as proof of significant disability. The difficulty of obtaining such records is obvious to even a lay person. It was an impossible ask to have such records over such a long period of time. A weakness of the scheme is that younger applicants whose records are more likely to be preserved and whose doctors are more likely to be in a better position to confirm that the applicant has had a symphysiotomy would be more likely to benefit from the scheme and to receive redress. For many women, Judge Harding Clark's dismissal of these claims was based on the lack of a document trail spanning many decades.

Judge Harding Clark fails to hold hospitals and medics responsible for keeping that documentation. Those who were unsuccessful in that application had no right of appeal. Not every woman sought redress through the scheme. Some sought compensation through legal action against the State. Their reasoning was clear. It was the State that effectively promoted symphysiotomy as a preferred option to a caesarean section, even when other jurisdictions prohibited that procedure. For some women, it makes sense to sue the State. Taking on the State has its own stresses, of course. It is difficult at the best of times for people to engage in legal proceedings. It is even more difficult if one has been traumatised to engage in such proceedings. It is more difficult depending on one's age and the stress and trauma involved. Women have suffered all their lives with the consequence of symphysiotomy. Some have this impact all of their lives, on their families and on their physical and mental health. I do not think this report has healed old wounds, and in some cases it has opened new ones. In many cases, these women deserve better.

I thank Senators for the contributions. I acknowledge Senator Reilly's role in establishing the scheme in his time as Minister for Health. The aim of the Government was to put in place a person-centred scheme for those who had a surgical symphysiotomy, to help bring closure for as many women as possible.

I believe the scheme has helped to bring that closure to a large number of women, and I welcome that.

The surgical symphysiotomy payment scheme was established in November 2014 following engagement by the then Minister for Health with the three patient advocacy groups that support women who underwent the procedure; and following consideration of two independent reports, the first from Professor Oonagh Walsh and the second from Judge Yvonne Murphy. Both of these expert reports recommended redress for the women who had undergone this procedure.

Two of the support groups welcomed the scheme and stressed the importance of providing redress for the women, given the older age group to which many of the women belong. One of the groups rejected the scheme. The scheme provided an alternative, non- adversarial and person-centred option for women, many of whom were elderly, and did not wish to pursue their cases through the courts. It was important that the women themselves had an opportunity to express their views regarding what might bring closure and Professor Walsh's research included a national public consultation process, with the women themselves and with other interested bodies. The report prepared by Judge Murphy also included direct meetings with the women regarding what would bring closure for them.

Judge Harding Clark also provided a comprehensive report on the surgical symphysiotomy payment scheme in October last year and we now have available a thorough overview of the historical and medical context of symphysiotomy, including published material from the annual clinical reports of the major maternity hospitals between 1940 and 1960 and extracts from the transactions of the Royal Academy of Medicine between the 1940s and the 1960s. This shows that symphysiotomy was not a secret procedure or an illegal procedure, but its rare use was reviewed and discussed by obstetricians at the time.

The total cost of the symphysiotomy payment scheme was just under €34 million and payments of €50,000, €100,000 or €150,000 were made to 399 women, who met the criteria for an award, the majority of whom were aged over 75 years. Although the scheme was non-adversarial, it provided for women to have their own independent legal advice and assistance in submitting their applications to the scheme. In the interests of accountability, the scheme required each applicant to prove that she had a surgical symphysiotomy or pubiotomy in order to be considered for the assessment of an award. All assistance possible was given to the women by Judge Harding Clark and her team in establishing this proof, which was considerably lower than the burden of proof required by the courts. It was only on accepting an award under the scheme that a woman had to discontinue her legal proceedings. The vast majority of women opted to do so.

The scheme was administered to the highest standards in line with its terms of reference. Many hundreds of hours were spent examining the applicants' medical records and each application received an individual, careful and fair assessment. The scheme did not hold any original medical records and at the end of the scheme, all applications and supporting documents were returned to the applicants or were confidentially shredded in line with each applicant's wishes. Regarding those women who were unable to establish that they had a surgical symphysiotomy, the report states that all of these applicants were assisted by members of the team in trying to establish their claims and the scheme's resources were applied in rigorous investigations before a claim was declared ineligible for the scheme.

Symphysiotomy is cited in several modern obstetric textbooks and has its place in obstetrics in limited circumstances, for example, it may still be used in the western world in the delivery of a trapped head in breech delivery or in emergency obstetric situations. It is not a banned procedure. One of the principal reasons for use of symphysiotomy in rare circumstances historically was the danger associated with caesarean section which was very real in Ireland in the 1950s and 1960s.

On the question of consent, based on the evidence available to the Department of Health, it would appear that in a number of cases the procedure was carried out with a woman's knowledge or consent. However, this was not the case in all hospitals. Hospital records in some instances showed that it was an elective procedure. The symphysiotomies in Our Lady of Lourdes Hospital, Drogheda, include a high number of elective procedures which would have been carried out with patient consent. Some 20% of respondents to Professor Walsh during her research were private patients. As I referred to earlier, the outmoded procedure of pubiotomy was only found to have been performed in one case and significant disability was established in this case.

The health of women affected by symphysiotomy has continued to be a priority. Medical services, including medical cards, are facilitated for the women by HSE nominated symphysiotomy liaison officers based around the country. These services are available whether or not a woman has availed of the scheme. Judge Harding Clark noted in her report that very detailed and forensic examination of available contemporaneous medical records failed to find evidence of religious as opposed to obstetric reasons why a symphysiotomy operation was performed. She also noted that the medical indications for symphysiotomy was always provided.

The Government hopes that the payments made to women under the surgical symphysiotomy payment scheme have helped to bring closure to women who underwent surgical symphysiotomy and to their families.

Sitting suspended at 4 p.m. and resumed at 4.30 p.m.