Savita Halappanavar case

Agnieszka_88

Stheno wrote: »

Polands laws are more liberal than ours allowing for it in the case of
When the woman's life or health is endangered by the continuation of pregnancy,
When the pregnancy is a result of a criminal act, or
When the fetus is seriously malformed

Malta has a complete ban on abortion.

Yes, that's true, but every Polish doctor has a right to refuse abortion on religious grounds (even pharmacists can refuse to sell contraception), and since there are cases where a doctor has lost their license because the court has decided that the patient's life wasn't in danger, they usually choose to use this right. Also, it's only legal until the 12th week into the pregnancy.
All in all, the Polish law is only more liberal in theory. Poland has been repeatedly sued in Strassburg (IT described the latest case here). Still, nothing changed and from what I've read recently, they intend to make their laws even stricter.

I didn't know about Malta. I guess it's always the small island countries that get forgotten.

drkpower

Truman Burbank wrote: »

This tragedy is not difficult to decipher. There was no legal impediment to performing surgery at an earlier date. This is looking black and white, not grey.

Im not sure where you are getting this from?

Clearly, we need to hear the facts of this case before definitively commenting. Notwithstanding that, there is at least a reasonable possibility that the medical team were prevented from intervening earlier (while the foetus had a heartbeat) on the basis that there was not yet a substantial risk to the life of the mother, an assessment that is inherently difficult due to the total absence of any guidelines (legal or medical) as to what precisely the phrase means.

Where an incorrect assessment in that regard can lead to a loss of one's livelihood or even freedom, it is easy to see how a medical team might be inclined to delay in providing treatment, even if that treatment was in the best interests of the mother.

Jessibelle

Just in light of the news today regarding the board of enquiry, is it usual to have as many representatives of the examined hospital on the investigative team, or is this an unusual circumstance? I'm aware the staff members weren't involved in the case itself.

opinion guy

Breaking news is that the local staff have been removed from the board:

http://www.irishtimes.com/newspaper/breaking/2012/1120/breaking1.html

Truman Burbank

drkpower wrote: »

Im not sure where you are getting this from?

Clearly, we need to hear the facts of this case before definitively commenting. Notwithstanding that, there is at least a reasonable possibility that the medical team were prevented from intervening earlier (while the foetus had a heartbeat) on the basis that there was not yet a substantial risk to the life of the mother, an assessment that is inherently difficult due to the total absence of any guidelines (legal or medical) as to what precisely the phrase means.

Where an incorrect assessment in that regard can lead to a loss of one's livelihood or even freedom, it is easy to see how a medical team might be inclined to delay in providing treatment, even if that treatment was in the best interests of the mother.

Are you saying that OBGYNS, the length and breadth of this Island, are not performing any terminations in (let's say) an exact clinical presentation such as this, i.e before an acute clinical deterioration? A yes or no answer appreciated.

opinion guy

I think its worth bearing in mind here that Prof Eamon O Dwyer, who was one of those folks who signed the Dublin Declaration 2 months ago stating therapeutic termination is never necessary and formerly ran Galway OBGYN services has been reported to have said she should have had a termination:
http://www.independent.ie/national-news/leading-gynaecologist-urges-use-of-international-experts-for-savita-inquiry-3296308.html

drkpower

Truman Burbank wrote: »

Are you saying that OBGYNS, the length and breadth of this Island, are not performing any terminations in (let's say) an exact clinical presentation such as this, i.e before an acute clinical deterioration? A yes or no answer appreciated.

Oh, if only yes/no answers worked in this debate.......

The honest answer to your specific question is I dont know. What I do know (and I speak as a medical lawyer, and doctor in a past life - whether that adds any weight to my argument is for others to decide) is that the law does not allow for the treatment of a woman (which includes a termination) whose:
- health, but not life, is at risk;
- life is at risk, but not to a substantial degree.

What I also know is that the word 'substantial' is not explained or elaborated upon anywhere, not in law, not in ethical or medical guidelines. Does it cover a 1 in 10 chance of death? Or a 3 in 10 chance? I'm not quite sure. Nor is anyone else.

What I also know is that there are medical complications of pregnancy that can cause a risk to a mother's health (with a negligible risk of death), which if left untreated can then subsequently cause a relatively low risk to the mother's life which, in turn, if left untreated might then pose a very serious risk to the mother's life. Along that spectrum, particularly at the beginning of the spectrum, where can a doctor act to protect the mother? I'm not sure. Nor is anyone else.

And finally, what I know is that the Master and ex-MAster of Holles St (amongst others) have stated that the current law creates grey areas in which they have no adequate legal clarity. So you can reallly ignore the last 3 paragraphs of my thoughts and just stick with this take home point:

If those who provide care to pregnant women are not, in some circumstances, clear as to what treatment they can provide under the law, there is a problem. And that problem needs fixing.

Snickers Man

OMD wrote: »

I don't think the answer is remotely clear but as you say an enquiry may give the answer. I think a lot of people have jumped to conclusions that sound to me like the wrong conclusions

That's true of people on both sides of the "Woman's right to choose" debate. There was a former nurse on the Frontline programme on RTE on Monday night who was adamant that any termination would not have been guaranteed to save the woman's life.

On the other hand, those people who went marching with a "Never Again" banner are evidently convinced that an early termination would have saved her life.

Unless they mean "Never again will a woman die of septicaemia in an Irish hospital" With the greatest of respect to our medical professionals and our maternity services, statistically ranked among the best in the world: Dream on.

his_dudeness

drkpower wrote: »

What I also know is that the word 'substantial' is not explained or elaborated upon anywhere, not in law, not in ethical or medical guidelines. Does it cover a 1 in 10 chance of death? Or a 3 in 10 chance? I'm not quite sure. Nor is anyone else.

What I also know is that there are medical complications of pregnancy that can cause a risk to a mother's health (with a negligible risk of death), which if left untreated can then subsequently cause a relatively low risk to the mother's life which, in turn, if left untreated might then pose a very serious risk to the mother's life. Along that spectrum, particularly at the beginning of the spectrum, where can a doctor act to protect the mother? I'm not sure. Nor is anyone else.

Very important point in this arguement/discussion that you've alluded to, is the perception of "substantial" risk.

This is going to be different for every body and was quite nicely put by one of the obstetricians on last nights Vincent Brown.

Take a 27y old, first pregancy, no health issues, happy relationship, wants the baby, a e.g. 1 in 3 chance of death may be something they might be willing to put up with, or may not.

Similarly, early-40y lady, first pregnancy after rounds and rounds of IVF, really really wants the baby, she may be willing to put up with a 50% risk, or even greater, to her life.

And then at the other stage, 16 year old girl, unintentional, unwanted pregnancy, too terrified to tell her parents etc, anything over 5% may be too much for her.

Not too mention a doctors impression of how sick a patient is/could be, their experience of recovering patients from septic shock etc.

It's going to run and run until the facts are out......

drkpower

his_dudeness wrote: »

Very important point in this arguement/discussion that you've alluded to, is the perception of "substantial" risk..

Absolutely, very good point. I think it was peter boylan on primetime.

The SC didnt say whether the words 'substantial risk to life' was to be judged by the woman, or by the doctor, or was to be viewed from the perspective of the mother, the doctor, or the hypothetical reasonable (wo)man.

Just another area of uncertainty.

Truman Burbank

drkpower wrote: »

Where an incorrect assessment in that regard can lead to a loss of one's livelihood or even freedom, it is easy to see how a medical team might be inclined to delay in providing treatment, even if that treatment was in the best interests of the mother.

No, it is not easy to see how a medical team......... There is a non-viable fetus; a mother with symptoms (and probable signs) of sepsis and someone is still checking for a fetal heartbeat? Please.

Thank you for your credentials - appreciated and acknowledged. As you know, I am not a lawyer but I do know, practically speaking, that I would classify 'septic' as a real and substantial risk, in the absence of a desktop dictionary on the term, because the patient could die. A skilled clinician should not need that desktop dictionary, at that moment in time (regardless of its existence or non-existence), because moments make minutes and all those minutes tick by, often rapidly, and look what happens. "Learning points" as the MPS would say. I must be thinking of a different standard of care. Assessment should be correct, otherwise we are all in trouble. That's patients I mean.

I never said there doesn't need to be clarity - I said that, in this case, on what we know (admittedly from one party), there is nothing grey to me about it.

ballsymchugh

Truman Burbank wrote: »

No, it is not easy to see how a medical team......... There is a non-viable fetus; a mother with symptoms (and probable signs) of sepsis and someone is still checking for a fetal heartbeat? Please.

Thank you for your credentials - appreciated and acknowledged. As you know, I am not a lawyer but I do know, practically speaking, that I would classify 'septic' as a real and substantial risk, in the absence of a desktop dictionary on the term, because the patient could die. A skilled clinician should not need that desktop dictionary, at that moment in time (regardless of its existence or non-existence), because moments make minutes and all those minutes tick by, often rapidly, and look what happens. "Learning points" as the MPS would say. I must be thinking of a different standard of care. Assessment should be correct, otherwise we are all in trouble. That's patients I mean.

I never said there doesn't need to be clarity - I said that, in this case, on what we know (admittedly from one party), there is nothing grey to me about it.

i'm inclined to agree here, but we need to know when it was accepted that it was miscarriage occuring as at that point, i don't understand why, as truman said, they were still checking the foetal heartbeat.

when is the tipping point?? the report will be interesting.

goodie2shoes

i agree we need to await the outcome of any inquiry.

far too many people have pre-judged this case in order to advance their own particular bandwagon/agenda, which i find disgusting.

they've swooped on this poor woman's death like vultures.

that said i do not think any one person should dictate what kind of inquiry the Govt. (our elected representatives) decide to establish.

frfintanstack

drkpower wrote: »

If those who provide care to pregnant women are not, in some circumstances, clear as to what treatment they can provide under the law, there is a problem. And that problem needs fixing.

Surely the law can never prescribe how to manage every clinical situation that may or may not arise. Be it pregnancy related or end of life care or whatever..... As stated above in difficult circumstances that's where a skilled and experienced physician makes a call based on the individual case. Laws cant be so nuanced.

The clamouring for legislation seems like a bit of a red herring to me....I don't see how a doctor could have ended up being prosecuted over ending an inevitable miscarriage where the womans cervix was open and there was a good chance that the longer it went on the risk of septicaemia increased. I've heard at least 3 obstetricians (including 2 current masters of maternity hospitals) stating there was nothing in current irish law to stop a termination in this case.

People are clamouring that we are 20 years waiting for legislation....well for 20 years we have coped and medics have managed miscarriages every day.

Or perhaps the pro-choice side are seeing this legislation as a stepping stone to legalising abortion.

I myself am pro-choice with a small "p" but the more this story develops the more uneasy I feel with how this story is being exploited to further the pro-choice side.

This is a terrible tragedy for the family of this lady....but also for the medical staff involved.

Loafing Oaf

drkpower wrote: »

And finally, what I know is that the Master and ex-MAster of Holles St (amongst others) have stated that the current law creates grey areas in which they have no adequate legal clarity. So you can reallly ignore the last 3 paragraphs of my thoughts and just stick with this take home point:

If those who provide care to pregnant women are not, in some circumstances, clear as to what treatment they can provide under the law, there is a problem. And that problem needs fixing.

I'm not sure which, but some of the obstetricians I've heard commenting on this case are implying, if not quite asserting outright, that the problem ultimately lies with Article 40.3.3, and until that is repealed there will always be a 'sword of damocles' hanging over their practice.

drkpower

Truman Burbank wrote: »

.....I would classify 'septic' as a real and substantial risk, in the absence of a desktop dictionary on the term, because the patient could die. .

'Septic' really just means 'infective', and I dont think any serious legal analysis would find that any infection could be considered in law to be a substantial risk to life complication.

The reality is that almost every condition under the sun could result in the death of the patient. The problem is determining when that negligible/theoretical risk becomes a substantial risk for the purposes of the law.

Truman Burbank wrote: »

I never said there doesn't need to be clarity - I said that, in this case, on what we know (admittedly from one party), there is nothing grey to me about it.

To you....

drkpower

frfintanstack wrote: »

Laws cant be so nuanced..

But they can be more nuanced than they are now.

frfintanstack wrote: »

The clamouring for legislation seems like a bit of a red herring to me....I don't see how a doctor could have ended up being prosecuted over ending an inevitable miscarriage where the womans cervix was open and there was a good chance that the longer it went on the risk of septicaemia increased....

You may not see how, but if the docs erred in his assessment that there was a substantial risk to this lady's life, then a prosecution is quite possible. My own view is that the mis-judgment would need to be quite significant to warrant a prosecution, but the risk is still there and where the consequences are so significant for the doctor, I can certainly see why it might influence the manner in which they proide care.

frfintanstack wrote: »

I've heard at least 3 obstetricians (including 2 current masters of maternity hospitals) stating there was nothing in current irish law to stop a termination in this case...

And I've heard one current, and one ex Master say there is a lack of legal clarity, as well as numerous lawyers who practice in the area. The fact that there are widely varying bone fide views on the legal position is surely indiciative of confusion, and accordingly the need for legal clarity.

drkpower

Loafing Oaf wrote: »

I'm not sure which, but some of the obstetricians I've heard commenting on this case are implying, if not quite asserting outright, that the problem ultimately lies with Article 40.3.3, and until that is repealed there will always be a 'sword of damocles' hanging over their practice.

That is because legislation can only clarify the meaning of 'substantial risk to life'. It cannot permit termination where there is:
- a risk to life short of substantial
- a risk to health, but not to life

They would require a referndum. So even after legislation there will remain situations where a mother's health/life may be at risk, but where termination is illegal.

I'm not into law or anything to the Nth degree, but I think this is a case of medical negligence, and nothing to do with the Law in Ireland. Savita had an unborn child incompatible with life, developed an infection, unborn child should've been taken out there and then, but wasn't due to 'this is a catholic country' stuff - the doctor who said this is negligent. Never mind heartbeats of a foetus after it's been found incompatible with life- he/she's negligent for not complying with the request for termination, Irish law already permits what he /she refused.

A Neurotic

Sweetface wrote: »

I'm not into law or anything to the Nth degree, but I think this is a case of medical negligence, and nothing to do with the Law in Ireland. Savita had an unborn child incompatible with life, developed an infection, unborn child should've been taken out there and then, but wasn't due to 'this is a catholic country' stuff - the doctor who said this is negligent. Never mind heartbeats of a foetus after it's been found incompatible with life- he/she's negligent for not complying with the request for termination, Irish law already permits what he /she refused.

Three criteria for negligence:

A. The doctor has a duty of care to the patient.

B. The duty of care is breached.

C. The patient comes to harm DUE TO that breach.

As I understand, it remains to be seen whether the harm that came to Savita was due to a breach in duty of care?

Open to correction on this as I haven't caught up with the story in the last day or two.

Loafing Oaf

Deleted User wrote: »

I'm not into law or anything to the Nth degree, but I think this is a case of medical negligence, and nothing to do with the Law in Ireland. Savita had an unborn child incompatible with life, developed an infection, unborn child should've been taken out there and then, but wasn't due to 'this is a catholic country' stuff - the doctor who said this is negligent. Never mind heartbeats of a foetus after it's been found incompatible with life- he/she's negligent for not complying with the request for termination, Irish law already permits what he /she refused.

Has this been definitively established though, or is the law in this area so vague that the consultant could make a legally defensible case that they were acting in compliance with it?

Until the enquiry is completed, we'll never know what really happened.

Listening to what this lady's husband had to say, what you say in A, B and C were all committed. I'm not quoting directly, but the husband said that although his wife was carrying an incompatible foetus, she was refused a termination. The doctor's duty of care was breached after the refusal of terminaton of an incompatible-with life-foetus, heartbeat or not, and Savita's life at risk (she must've been feeling extremely unwell if she developed septacemia which doctors should've been monitoring on her in the first place), which is permissable by Irish law. But we won't know until all the facts are out.

Flier

Deleted User wrote: »

...I think this is a case of medical negligence, and nothing to do with the Law in Ireland. ......he/she's negligent for not complying with the request for termination, Irish law already permits what he /she refused.

Deleted User wrote: »

.....and Savita's life at risk (she must've been feeling extremely unwell if she developed septacemia which doctors should've been monitoring on her in the first place)

Really, sometimes I just want to find a wall to bang my head against. Despite the fact that we don't know the exact circumstances, despite the explainations by lawyers and medical lawyers on this thread, you can come out with such a statement.
And 'feeling extremely unwell' isn't even close to being a 'real and substantial risk to life'. And I'll stand by that even without the facts of this particular case.

opinion guy

drkpower wrote: »

'Septic' really just means 'infective', and I dont think any serious legal analysis would find that any infection could be considered in law to be a substantial risk to life complication.

Eh...... what ???

drkpower

opinion guy wrote: »

Eh...... what ???

what bit?!

opinion guy

drkpower wrote: »

what bit?!

Eh.....various bits and as a whole. Sorry its a confusing sentence.

Also.
'septic' whilst not a precise term, does imply more than just infectious - it implies so infected as to be quite ill. No ? If someone had an infection with no symptoms and no ill health they generally wouldn't be called 'septic'. They'd be called infectious. You don't say 'infectious shock', you say 'septic shock'

And are you saying that no infection could be considered life threatening ?

What about meningitis ??? Or necrotising fasciitis ? Or even ESBL E coli septicaemia ???? Or what about when you don't know the source or cause of infection but you know there is one?

goodie2shoes

i think people are so sick 'n tired of this story already.

drkpower

opinion guy wrote: »

Eh.....various bits and as a whole. Sorry its a confusing sentence.

Yeah, in fairness, I could have phrased it better!

Re 'septic', i hear what you are saying but septic/sepsis really just does mean 'infective'. I appreciate though that it tends to be associated in common parlance with more 'serious' infections (septic arthritis, septic shock etc). But in any case, it is a bit of a side issue.

opinion guy wrote: »

And are you saying that no infection could be considered life threatening ?

No, im not saying that. Im saying that what is required is more than just a mere infection, or in the vernacular, more than 'any old' infection. Get what im saying now?

his_dudeness

A Neurotic wrote: »

Three criteria for negligence:

A. The doctor has a duty of care to the patient.

B. The duty of care is breached.

C. The patient comes to harm DUE TO that breach.

As I understand, it remains to be seen whether the harm that came to Savita was due to a breach in duty of care?

Open to correction on this as I haven't caught up with the story in the last day or two.

Another aspect of proving negligence is that the practice would have been different from what other doctors would've done in the same situation.

Odds are it would be very difficult to prove that other doctors would've done differently without suggesting there is widespread breaking of the law.

opinion guy wrote: »

Eh.....various bits and as a whole. Sorry its a confusing sentence.

Also.
'septic' whilst not a precise term, does imply more than just infectious - it implies so infected as to be quite ill. No ? If someone had an infection with no symptoms and no ill health they generally wouldn't be called 'septic'. They'd be called infectious. You don't say 'infectious shock', you say 'septic shock'

And are you saying that no infection could be considered life threatening ?

What about meningitis ??? Or necrotising fasciitis ? Or even ESBL E coli septicaemia ???? Or what about when you don't know the source or cause of infection but you know there is one?

Septic is a vague term, but roughly would be signs of systemic inflammation, I.e. changes in blood tests, with evidence of infection.

Septic Shock is very specifically defined.

http://www.survivingsepsis.org/Introduction/Pages/default.aspx



There is the obvious problems in the media reporting where lay terms and medical terminology are being intertwined when there meanings are different.

opinion guy

his_dudeness wrote: »

Septic is a vague term, but roughly would be signs of systemic inflammation, I.e. changes in blood tests, with evidence of infection.

Septic Shock is very specifically defined.

http://www.survivingsepsis.org/Introduction/Pages/default.aspx



There is the obvious problems in the media reporting where lay terms and medical terminology are being intertwined when there meanings are different.

Yes thanks for making the same point as me with different words