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Conference of Doom: How red tape may cost a woman her life




There has been a lot of talk lately about how Bill 28, a historic Bill that will legalise termination of pregnancy in cases of risk to the woman's life or grave risk to her health, could be watered down to appease conservatives. One such measure that has been floated numerous times is requiring more than one doctor to approve the termination of pregnancy. Proponents of this measure argue that it would introduce safeguards against "abuse," but in reality it would serve no clinical purpose, add no value to the woman's care, and introduce delays and additional risks that may cost a woman her life.



Do we no longer trust doctors now?


Government MPs have been rightly placing trust in doctors to make a good assessment of a woman's health status and intervene when the parameters set out in law are met. This has also been used to score points against Opposition MPs when these claimed the law could be "abused," which implies they do not have trust in some or all doctors.


As it stands, the proposed law will not require more than one doctor to make a decision to terminate the pregnancy. This is as it should be, because the doctor who has the clearest picture of the patient's status is the doctor involved in providing direct clinical care to the patient. In a hospital setting, there would be a hierarchy of doctors and such a decision would be taken by a senior Obstetrician even if the patient is initially clerked by a junior doctor. This is established practice in hospital settings.


Backtracking on the principle of trusting doctors and adding a requirement in law for more than one doctor to approve the termination of pregnancy would introduce delays, especially if it is an emergency unfolding out of hours. It may be the case that a qualified Obstetrician, who is perfectly capable of making thorough assessment and wise judgements, is unable to find a second doctor in good time. Another layer of complexity is that different doctors have different values and opinions, and some may require a higher level of risk than others to approve a termination of pregnancy. Requiring two or more doctors to give their approval will almost certainly result in the woman being forced to face more risk before a unanimous decision is issued, and this will dilute the protection to women the law provides.



A Conference or Board would be even more deadly.


An even worse idea that has been floated about is requiring not just more than one doctor, but requiring a "conference" of doctors including the patient's GP and the clinical lead in hospital. This is an unworkable arrangement, especially in Malta where patients may not have a fixed GP. It is also common for GPs to be unaware of a pregnancy in its early stages, as women can self-diagnose a pregnancy using a home testing kit. A GP may not have examined the patient before going into hospital because a patient experiencing acute complications may take themselves straight to A&E. It is unfair to ask a GP, who is unlikely to know the patient's current state in hospital, to be involved in a decision on whether or not to terminate a pregnancy.


Involving a clinical lead or anyone else in a fixed position is problematic, and introduces risks at many levels. The clinical lead may simply not be available, and even if there is a deputy it is conceivable that they could both be indisposed at the same time. It is unlikely that such people would be able to make a decision out of hours, and therefore the "conference" is likely to be scheduled the next available working day. This will simply not work for a woman with a life-threatening complication where every minute counts.


Another possible issue is the opinion of a person in a fixed position. If you have a person who will always, or nearly always, be involved in decisions about termination of pregnancy in Malta, this would be a position the anti-abortion lobby would do its best to fill with one of their own to influence practice. We have already seen the anti-choice openly push their candidates in the Medical Council election, and they will certainly do the same with such a post. With an anti-abortion person in that post, women who may qualify for a termination under the the law being proposed may be denied what is legal.



Comparing decisions about termination of pregnancy to decisions about withdrawing life support is like comparing chalk and cheese.


The proponents of having more than one doctors decide on termination of pregnancy often draw upon the fact that more than one doctor is involved in declaring brain death when life support is being withdrawn. However, one cannot compare a woman dying of pregnancy complications with someone on life support who will not recover. These are two completely different clinical scenarios.


Someone on life support would be relatively stable, albeit kept alive only by a machine. In these cases it makes sense to wait and involve more people in the decision, because one would also need to be certain that the patient is not showing signs of recovery. The patient in these cases is comatose and cannot give consent, so a decision must be made in their best interests by multiple people. The decision is also about whether to withdraw treatment, rather than give treatment.


A woman dying of pregnancy complications is fighting a race against time. The longer it takes to make a decision, the more likely she is to die. One simply does not have the luxury of time. Except in extreme cases, the woman would still be conscious and able to give her consent to treatment, so involving other people for a decision is unnecessary. In this case treatment is indicated and should be given (unlike in the previous case when treatment is being withdrawn), and it is immoral to delay life-saving treatment.


In summary, the government should trust doctors, and let the doctor best placed to make a decision, which is the doctor providing direct clinical care to the patient, get on with their work and save lives. Any additional requirements would have no clinical value and are simply red tape to appease conservatives. They will introduce delays and additional risks that may cost a woman her life, and this is exactly what this law is trying to avoid.

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