Savita Halappanavar case

MrCreosote · 14-11-2012 9:20pm #1

Presumably everyone has seen the recent case in Galway.

One thing that seems to have been overlooked is the fact that the E coli sepsis seems to have been caused by ESBL E coli. Is this common in Ireland? Possibly was a contributing cause if the antibiotics that were presumably given didn't work.

I don't want to debate the rights and wrongs of abortion law in Ireland (seems to be on plenty other forums), except to say that if a necessary medical procedure was delayed on non-medical grounds then there are serious ethical questions to be answered.

Withholding a termination on a foetus that is never going to survive is similar to delaying treating an ectopic pregnancy because it has a heart beat.

OMD · 14-11-2012 9:48pm

MrCreosote wrote: »

Presumably everyone has seen the recent case in Galway.

One thing that seems to have been overlooked is the fact that the E coli sepsis seems to have been caused by ESBL E coli. Is this common in Ireland? Possibly was a contributing cause if the antibiotics that were presumably given didn't work.

I don't want to debate the rights and wrongs of abortion law in Ireland (seems to be on plenty other forums), except to say that if a necessary medical procedure was delayed on non-medical grounds then there are serious ethical questions to be answered.

Withholding a termination on a foetus that is never going to survive is similar to delaying treating an ectopic pregnancy because it has a heart beat.

The problem is we don't know the relevance or not of the termination. Would the termination have increased her chances of survival?

opinion guy · 14-11-2012 10:08pm

There is an interview with the husband here - he gives alot of details on the time course of the case etc. I've not listened to the whole thing however.
http://www.irishtimes.com/audio/2012/11/savita.mp3

MrCreosote · 14-11-2012 10:52pm

OMD wrote: »

The problem is we don't know the relevance or not of the termination. Would the termination have increased her chances of survival?

I'm sure the investigations ongoing will clarify this. Going on what's in the media already, I think the answer is pretty clear.

Could a mod change the title from "Sativa" to "Savita" as well please? Sorry-misspelling.

frfintanstack · 15-11-2012 12:16am

Tragic case.....

Agree with this point...

MrCreosote wrote: »

Withholding a termination on a foetus that is never going to survive is similar to delaying treating an ectopic pregnancy because it has a heart beat.

surely this case is about management of an "inevitable miscarriage" and has nothing to do with abortion?

3 options; expectant, medical or surgical management. Nothing to stop medics using any of these options.

Expectant management is a perfectly valid method.

Suppose we wont know until its investigated fully.

I'd wonder about the husbands assertion that he was told that because the foetal heartbeat was still present and they were told, “this is a Catholic country”.

Sounds bizarre to me.

OMD · 15-11-2012 8:00am

MrCreosote wrote: »

I'm sure the investigations ongoing will clarify this. Going on what's in the media already, I think the answer is pretty clear.

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

RacoonQueen · 15-11-2012 8:14am

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

I was thinking this as well. Seems to be a lot of bandwagon jumping and everyone automatically assuming that it is an abortion issue.

We know very few facts of the case other than what the media have publicised(sensationalised?). Is there a certain protocol in cases of this nature? When did they know she had an infection? Is it against the rules to 'abort' the foetus while it still has a heartbeat even though it's clear it won't survive?

MrCreosote · 15-11-2012 8:33am

frfintanstack wrote: »

3 options; expectant, medical or surgical management. Nothing to stop medics using any of these options.

Expectant management is a perfectly valid method.

Unless there are complicating factors like heavy bleeding and particularly infection. In that case urgent surgical management is mandatory. Antibiotics might buy time, but as it seems ESBL E coli was involved they won't be effective.

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

If the husband's account is accurate in terms of timing, and there's nothing to suggest it isn't, then it is pretty clear what happened (or more accurately, didn't happen). If this was as a result of a clinician's religious views, then it's an ethical disaster.

RacoonQueen wrote: »

We know very few facts of the case other than what the media have publicised(sensationalised?). Is there a certain protocol in cases of this nature? When did they know she had an infection? Is it against the rules to 'abort' the foetus while it still has a heartbeat even though it's clear it won't survive?

If there is a direct threat to the mother's life then it is legally allowed. If there isn't only a threat to her health, as opposed to her life, then it is illegal. This is bullsh*t legal black-and-white speak though which is almost impossible to apply to the real world. Almost everything that has a threat to "health" has a threat to life as well- so you're entering a grey area where it's not clear where the legal lines are drawn. My feeling is that very few clinicians want to be the test-case to see where the boundaries are set, and as for the politicians legislating for this...well, we've only been waiting 20 years.

seamus · 15-11-2012 9:24am

MrCreosote wrote: »

If there is a direct threat to the mother's life then it is legally allowed. If there isn't only a threat to her health, as opposed to her life, then it is illegal. This is bullsh*t legal black-and-white speak though which is almost impossible to apply to the real world. Almost everything that has a threat to "health" has a threat to life as well- so you're entering a grey area where it's not clear where the legal lines are drawn. My feeling is that very few clinicians want to be the test-case to see where the boundaries are set, and as for the politicians legislating for this...well, we've only been waiting 20 years.

+1

I think this sums up the entire issue very well. The clinicians involved no doubt recognised the danger to the poor woman's health but didn't feel that they could legally justify aborting the foetus on the basis of risk to life. Obviously there reaches a point where a risk to health becomes a risk to life, but without any firm law on it clinicians are always going to err on the side of caution and action won't be taken until the danger has been allowed to go further than it should have.

OMD · 15-11-2012 11:59am

MrCreosote wrote: »

If the husband's account is accurate in terms of timing, and there's nothing to suggest it isn't, then it is pretty clear what happened (or more accurately, didn't happen). If this was as a result of a clinician's religious views, then it's an ethical disaster.
.

At what stage was the septicaemia diagnosed? From what I can gather it was after the miscarriage.

At what stage would a reasonable doctor have concluded that an abortion was necessary?

Did the consultant feel an abortion was necessary but refused to do it in either legal or moral grounds? From my reading of it the answer is no but as I say we don't yet know.

We need answers to these questions and many more before we jump to conclusions

OMD · 15-11-2012 2:16pm

Just in addition to the above I saw this in the Irish Times. I am not sure if Simon Mills knows any more about this case than the rest of us but he is quoted as saying:
"As barrister Simon Mills points out, on the available facts, it does not appear Ms Halappanavar was facing a substantial threat to her life until after her baby was delivered."
This is pretty much what I have been saying and is an important point to be clarified.

opinion guy · 15-11-2012 3:44pm

OMD wrote: »

Just in addition to the above I saw this in the Irish Times. I am not sure if Simon Mills knows any more about this case than the rest of us but he is quoted as saying:
"As barrister Simon Mills points out, on the available facts, it does not appear Ms Halappanavar was facing a substantial threat to her life until after her baby was delivered."
This is pretty much what I have been saying and is an important point to be clarified.

I think this is worth a read:
http://drjengunter.wordpress.com/2012/11/14/did-irish-catholic-law-or-malpractice-kill-savita-halappanavar/

Since posting this piece I learned that Ms. Halappanavar’s widower reported that she was leaking amniotic fluid and was fully dilated when first evaluated. There is no medically defensible position for doing anything other than optimal pain control and hastening delivery by the safest means possible.

_Whimsical_ · 15-11-2012 5:02pm

frfintanstack wrote: »

surely this case is about management of an "inevitable miscarriage" and has nothing to do with abortion?

3 options; expectant, medical or surgical management. Nothing to stop medics using any of these options.

Expectant management is a perfectly valid method.

I was just wondering about this point. Obviously it is impossible to answer any questions with regard to this case as so few of the facts are apparent. I presume "expentant management" is not intervening and allowing nature take it's course?

Is it very unusual for miscarriage to take place over a course of days? Is "expectant management" an uncommon approach? Generally in a physicians mind is this course of action seen as more potentially life threatening than another?

It's such a dreadfully sad case and the growing hysteria around it is quite frightening when there are so few facts. It is sad that the media and public won't afford such a tragic situation the reflection it deserves and wait for more of the facts without hijacking it as fuel to the fire of their own agenda.

frfintanstack · 15-11-2012 5:39pm

_Whimsical_ wrote: »

Is it very unusual for miscarriage to take place over a course of days? Is "expectant management" an uncommon approach? Generally in a physicians mind is this course of action seen as more potentially life threatening than another?

It isn't at all uncommon for a miscarriage to pass over a few days.

Expectant management is used commonly. Although its not suitable if there is heavy bleeding or infection present. But we don't know when the infection started here.

There are risks to all 3 methods,

maternal mortality during ERPC (surgical removal of foetus) is quoted at 14/100,000 so its not without risks either.

Its hard to work out what happened when we have so few facts about this case.

I'm amazed by the public reaction, mostly about the outpouring of self loathing about us Irish being somehow backward.

Something went wrong here but IMO it had nothing to do with Irish abortion law....

There was nothing in irish law to stop the doctors managing this miscarriage medically or surgically......it happens everyday!

MrCreosote · 15-11-2012 6:28pm

frfintanstack wrote: »

It isn't at all uncommon for a miscarriage to pass over a few days.

Expectant management is used commonly. Although its not suitable if there is heavy bleeding or infection present. But we don't know when the infection started here.

There are risks to all 3 methods,

maternal mortality during ERPC (surgical removal of foetus) is quoted at 14/100,000 so its not without risks either.

Its hard to work out what happened when we have so few facts about this case.

All the facts are in the original article. If they are accurate then I think it's clear the way things went:

http://www.irishtimes.com/newspaper/frontpage/2012/1114/1224326575203.html?via=mr

There were systemic signs of severe infection (fever, rigors and collapse) on the Tuesday. The ERPOC was delayed until the Wednesday afternoon after the foetal heart was checked again. It should have been performed immediately, regardless. How someone can say there is only a threat to the mother's health as opposed to life from sepsis is beyond me. All the arguments about other forms of management are moot at this point- if there is sepsis the correct treatment is surgical and antibiotics.

I'd agree that this seems to be a question of correct medical management rather than some challenge to abortion law, but for one reason- if what her husband says about medical staff saying "Abortion is banned" and "This is a Catholic country" is true then it immediately becomes about the need for proper legislation.

frfintanstack · 15-11-2012 6:52pm

MrCreosote wrote: »

I'd agree that this seems to be a question of correct medical management rather than some challenge to abortion law, but for one reason- if what her husband says about medical staff saying "Abortion is banned" and "This is a Catholic country" is true then it immediately becomes about the need for proper legislation.

Having been adjacent to a couple of stories that made it into the papers one should be careful calling the details in newspapers "facts". Especially when we only have a one sided story.

I cant believe that there is an obstetrician working in Ireland today who would say things like that.

For some reason it doesn't ring true to me (call me cynical)....but if they did they should be up in front of the medical council ASAP.

10000maniacs · 15-11-2012 9:17pm

india.png

I kind of agree with The India Times today (See Link above). The Catholic doctrine is still running this country.
It can be argued that The Catholic Church has claimed another victim. They have to be stopped before they do any more damage.

Jessibelle · 15-11-2012 9:24pm

The lack of clarity regarding abortion here is not a religious decision, it's a legal one. Purely government driven. If it was religious, abortion wouldn't be possible anywhere that there's organised religion. Legislative cowards are hiding behind convenient scape goats for this, to hide they've had nearly twenty years to legislate for this eventuality since the X case, which they have failed to do.
Also, blaming it on any religious institution runs the risk of enveloping any further legal decisions in more smoke and mirrors and then another delay on clarification.
I'm also curious as to the E.coli infection (I'm just a student at this point so don't know too much about how common that type of infection would be), any one know anywhere I couldl look for this information?

Truman Burbank · 15-11-2012 9:39pm

MrCreosote wrote: »

All the facts are in the original article. If they are accurate then I think it's clear the way things went:

http://www.irishtimes.com/newspaper/frontpage/2012/1114/1224326575203.html?via=mr

There were systemic signs of severe infection (fever, rigors and collapse) on the Tuesday. The ERPOC was delayed until the Wednesday afternoon after the foetal heart was checked again. It should have been performed immediately, regardless. How someone can say there is only a threat to the mother's health as opposed to life from sepsis is beyond me. All the arguments about other forms of management are moot at this point- if there is sepsis the correct treatment is surgical and antibiotics.

I'd agree that this seems to be a question of correct medical management rather than some challenge to abortion law, but for one reason- if what her husband says about medical staff saying "Abortion is banned" and "This is a Catholic country" is true then it immediately becomes about the need for proper legislation.

A bit of both, more of one and less of the other. The Irish Times audio in particular is harrowing. Her husband does not appear to realise that being brought to The HDU (after an ERPC) is not reassuring. Current link (make take a few minutes to load);

http://46.4.230.144/web/UpToDate.v19.2/contents/f31/26/32591.htm

http://www.uptodate.com/contents/midtrimester-preterm-premature-rupture-of-membranes?source=see_link

It's awfully quiet around here.

ballsymchugh · 15-11-2012 9:40pm

Truman Burbank wrote: »

A bit of both, more of one and less of the other. The Irish Times audio in particular is harrowing. Her husband does not appear to realise that being brought to The HDU (after an ERPC) is not reassuring. Current link (make take a few minutes to load);

http://46.4.230.144/web/UpToDate.v19.2/contents/f31/26/32591.htm

http://www.uptodate.com/contents/midtrimester-preterm-premature-rupture-of-membranes?source=see_link

It's awfully quiet around here.

empty vessels make the most noise. this may only be the second page, but it's the best thread on the situation on this site.

Truman Burbank · 15-11-2012 9:42pm

Jessibelle wrote: »

T
I'm also curious as to the E.coli infection (I'm just a student at this point so don't know too much about how common that type of infection would be), any one know anywhere I couldl look for this information?

http://www.cdc.gov/ecoli/
Also pubmed for article searches

Jessibelle · 15-11-2012 9:47pm

Truman Burbank wrote: »

http://www.cdc.gov/ecoli/
Also pubmed for article searches

Thanks. I've been to Pubmed but the quantity of research there is a bit vast for what I'm looking for. I was looking more for any good review papers if anyone knew of them, that said, my own fault for not being more precise. Thanks again.

Truman Burbank · 16-11-2012 9:48am

ballsymchugh wrote: »

empty vessels make the most noise. this may only be the second page, but it's the best thread on the situation on this site.

Indeed. Was referring to the conspicuous absence of regular posters. But there's no need to jump to conclusions here. 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.

MrCreosote · 16-11-2012 10:04am

Apparently ESBL organisms are not too uncommon in Ireland:

http://www.biomedcentral.com/1471-2334/12/116

The only recent study I could find, no true incidence figures unfortunately.

A Neurotic · 16-11-2012 2:50pm

Truman Burbank wrote: »

A bit of both, more of one and less of the other. The Irish Times audio in particular is harrowing. Her husband does not appear to realise that being brought to The HDU (after an ERPC) is not reassuring. Current link (make take a few minutes to load);

http://46.4.230.144/web/UpToDate.v19.2/contents/f31/26/32591.htm

http://www.uptodate.com/contents/midtrimester-preterm-premature-rupture-of-membranes?source=see_link

It's awfully quiet around here.

Can't access uptodate (poor student) - but I'm just wondering how common/foreseeable septicaemia is as a complication of PPROM?

Is this a situation where the medical team knowingly put the patient at increased risk of serious complications due to legal constraints?

Tree · 16-11-2012 3:41pm

MrCreosote wrote: »

Apparently ESBL organisms are not too uncommon in Ireland:

http://www.biomedcentral.com/1471-2334/12/116

The only recent study I could find, no true incidence figures unfortunately.

The HPSC track ESBL incidence, their 2010 report seems to indicate they account for 6.1% of isolates :-/

http://www.hpsc.ie/hpsc/AboutHPSC/AnnualReports/

Truman Burbank · 16-11-2012 9:18pm

A Neurotic wrote: »

Can't access uptodate (poor student) - but I'm just wondering how common/foreseeable septicaemia is as a complication of PPROM?

Is this a situation where the medical team knowingly put the patient at increased risk of serious complications due to legal constraints?

I've linked the uptodate article, in its entirety, above it. A number of these are downloaded. The intro for every one is available - that's the second link. As a student this is a great resource because not only does it give you a basic summary of the topic, it also provides the references below for further reading. There are several summaries, including a general one, I've only referenced the mid-trimester one here. Uptodate should be on your hospital, and Health Sciences library, desktop.

I would not think anyone would think like that. The patient is your raison d'etre.

panda100 · 18-11-2012 10:10am

frfintanstack wrote: »

Having been adjacent to a couple of stories that made it into the papers one should be careful calling the details in newspapers "facts". Especially when we only have a one sided story.

I cant believe that there is an obstetrician working in Ireland today who would say things like that.

There are very outspoken catholic conservatives in the medical profession. It wouldn't suprise me to heqr them say somethng like this.

Also,our hospitals are still run by religious orders,with members of the clergy sitting on the boards of most majory hospitals. It is up to them to uphold the Catholic doctrine in Irish hospitals. I remember it was for that reason, the morning after pill could not be prescribed in the Mater hospital, and you would have to send people to their gp for it.

partyatmygaff · 18-11-2012 2:01pm

ballsymchugh wrote: »

empty vessels make the most noise. this may only be the second page, but it's the best thread on the situation on this site.

Nearly every other thread on boards has descended in to a frenzy of people repeating and rewording the following opinion and thanking each other:
"Abortion would have definitely saved her life. It's all the Catholic church's fault, we're just an awful nation and should take criticism and make national apologies to the likes of India."

Suggesting the possibility that it's a legal and not a religious issue and/or that an abortion could very well have had no effect on the final outcome seems to fall on deaf ears. Everyone seems to just want a sensational story they can get worked up over and talk about.

Agnieszka_88 · 18-11-2012 5:10pm

partyatmygaff wrote: »

Nearly every other thread on boards has descended in to a frenzy of people repeating and rewording the following opinion and thanking each other:
"Abortion would have definitely saved her life. It's all the Catholic church's fault, we're just an awful nation and should take criticism and make national apologies to the likes of India."

Suggesting the possibility that it's a legal and not a religious issue and/or that an abortion could very well have had no effect on the final outcome seems to fall on deaf ears. Everyone seems to just want a sensational story they can get worked up over and talk about.

I definitely agree that the responses found everywhere on the internet are very emotional and that people seem to just accept everything as it's given without asking questions. But I do not agree that you can differ between legal and religious in this (and any similar) case. The fact is, that the only other European country with such a strict anti-abortion law is the obsessively catholic Poland (I spent a big part of my childhood there and trust me when I say that I know everything there is to know about the catholic doctrine being forced on people, whether it comes to lawmaking or education).
Whether abortion would have had an effect on the final outcome is important and should definitely be cleared, together with the procedures, but this case shows something else- that people feel that the archaic Irish abortion law should be reviewed, and that the church has no place in a democracy, indeed it shouldn't have such a huge influence on the law of a autonomous country. Some might say that the Health Sciences forum isn't the right place for such a discussion, but then where else?

Stheno · 18-11-2012 5:20pm

Agnieszka_88 wrote: »

The fact is, that the only other European country with such a strict anti-abortion law is the obsessively catholic Poland (I spent a big part of my childhood there and trust me when I say that I know everything there is to know about the catholic doctrine being forced on people, whether it comes to lawmaking or education).

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.

Agnieszka_88 · 18-11-2012 6:18pm

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 · 18-11-2012 6:32pm

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 · 20-11-2012 6:28pm

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 · 20-11-2012 6:39pm

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 · 20-11-2012 6:43pm

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 · 20-11-2012 6:48pm

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 · 21-11-2012 9:06am

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 · 21-11-2012 10:07am

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 · 21-11-2012 10:35am

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 · 21-11-2012 11:27am

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 · 21-11-2012 11:16pm

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 · 21-11-2012 11:33pm

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 · 22-11-2012 2:10pm

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 · 22-11-2012 6:18pm

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 · 23-11-2012 9:59am

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 · 23-11-2012 11:29am

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 · 23-11-2012 11:48am

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 · 23-11-2012 11:51am

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.

23-11-2012 1:07pm

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 · 23-11-2012 1:12pm

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.

Savita Halappanavar case

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