54 day to go…Mass appeal & UK two doctor model of abortion consent (part 3)

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54 days to go to Ireland’s referendum on abortion on May 25th where voters decide whether to repeal / remove the pro-life 8th amendment to the constitution which gives equal protection to mother and child, or to keep it. (Happy Easter: Jesus is risen, we took Good Friday off so the post is a day late, but o.k. cause we were to finish a day early…no loss 😊)

This post is in two parts:

(1): SR BRIEGE MCKENNA’S APPEAL:

FOR MASSES FOR IRELAND AND FOR THE 8TH AMENDMENT.

Everyday, we promote Sr. Briege McKenna’s appeal for Masses to be said privately or publicly in parishes in reparation for Ireland’s turning from God and for protection of the 8th amendment.  August last year in Knock, she said, ‘if Ireland votes for abortion, Ireland is lost.’ Please consider getting Masses said locally or through this link to ACN:

http://www.acnireland.org/masses or call 018377516.

Alternatively Human Life International Ireland have a 1000 Mass campaign for protection of the unborn and reparation for Ireland’s turning from God…

https://humanlife.ie/1000masses/community/add

Most importantly: can you with other parishioners organise one or more Masses / half-days or days of prayer with medically safe fasting in your parish?

The UK two doctor model of abortion consent: How does it work ?

(part 3)

Review: In parts 1 and 2, we looked at how a scandal was reported in early May 2014 in the Telegraph newspaper (1) over the pre-signing of abortion consent forms by 67 doctors during on the spot checks by the Care Quality Commission / C.Q.C. or health watchdog in 2012. This appeared to have happened at 14 out of 249 locations examined. The inspections followed a letter from the Chief Medical Officer in February 2012 to all providers of termination of pregnancy services making clear their responsibilities under the 1967 Abortion Act after a single case of pre-signing had been identified and all 14 found to be guilty of pre-signing were N.H.S. trusts (2). A cross-party group of M.P.s reported it to the Metropolitan Police and Earl Howe the Health minister in the House of Lords had said that prosecutions should result.

However the General Medical Council / G.M.C., found no case against the medics in question and stated the police had examined two sample cases and felt there was no ground for prosecution. The G.M.C. accepted that the practice was unacceptable and broke the law but refused to identify any doctors or their roles, stating that this was because it was so widespread, also stating that no woman had been harmed in the cases identified and because clinical practice had changed so much since the 1967 UK abortion act.

The G.M.C. warned the doctors in question not to do it again and said that the C.Q.C. watchdog had since established that the practice was no longer happening. They didn’t explain however what they meant by clinical practice having changed so much. It was not clear from the Telegraph report or the G.M.C. response, if patients were just being seen after the forms had been pre-signed (which would possibly risk oversights due to a sense of complacency in any consultation with a woman) or if the women simply hadn’t been seen at all by the 67 doctors.

The reaction of Earl Howe in the house of Lords and M.P.s seemed to suggest the latter rather than the former and the statement by the G.M.C. suggesting that pre-signing had been stamped out in follow ups by the health watchdog / C.Q.C., suggested that women were now being seen in consultation and consented in proper order by doctors as per the 1967 abortion act. This act requires that two doctors form an opinion in good faith that a woman seeking an abortions meets one of no. of potential grounds.

But within a fortnight the Telegraph reported  a public statement by the U.K. Dept. of Health / D.O.H., (3) that doctors could consult with a woman seeking an abortion by phone or Skype.

Most significantly, the Dept. stated that in fact under the 1967 act, there was absolutely no obligation on doctors to see a woman prior to an abortion. That while it was ‘good practice’, it was not mandatory. The option to Skype a woman before an abortion no doubt to facilitate more interaction between doctor and patient did not suggest consultations in person were always happening if indeed at all.

Just two weeks after the G.M.C.’s public reassurance that pre-signing had been stamped out, the statement by the U.K. Dept. of Health, suggested the G.M.C. absolutely knew that the doctors were not seeing women before abortions, but that there was no issue in the G.M.C. with that per se. So if there was no issue with the 67 doctors not seeing women prior to abortions, what did the pre-signing of consent forms mean practically if not failing to see a patient before a procedure? Wasn’t the furore because it was understood that a woman should be seen by two medics under the abortion act?

If this was the widespread practice that had changed radically since the 1967 act, the G.M.C. had adopted a position of not explaining this in its statement. A re-reading of the initial Telegraph report on the G.M.C.’s reaction to pre-signing,  in the light of the second D.O.H. report, shows that the G.M.C.’s comments on stamping out pre-signing, did not clarify or disabuse the public of the notion that women were now being seen and consented by doctors. This carefully worded statement by the G.M.C. belied the reality of what was really happening under the act but could be interpreted in different ways whether intended or not.

Probably under pressure from abortion providers and their doctors who had been investigated and reprimanded by the G.M.C., the D.O.H.  explained that the practice of doctors not seeing women before their abortions was not in fact breaking the law.

What was going on then, between the public positions of the G.M.C. who were insisting that that the law had been broken and that consent forms must not be pre-signed by medics and the position of the D.O.H. which stated publicly, that there was no onus at all on abortionists to see a woman before an abortion?

Part 3:

The puzzle:

The timing, a fortnight after the negative publicity for abortion providers in the UK, can only be a direct response to the pre-signing scandal and G.M.C. findings as reported in the Telegraph. Yet, the G.M.C. findings were actually not mentioned directly by the D.O.H. in the second article (though the article does quote Ann Furedi of British Pregnancy Advisory Service / B.P.A.S., the biggest abortion provider in the U.K.. who said they exonerated doctors. )

As a result of the Dept. of Health statement, the 67 medics that the C.Q.C. / health watchdog had found guilty of pre-signing consent forms and of breaking the law, were effectively exonerated by the British government on any perceived grounds that might be held by the public, of failing to see patients before abortions. Not in fact because they had actually seen patients before abortions: they hadn’t. But because the D.O.H. was now stating publicly that the 1967 act never required doctors to see the patient before the abortion!

But then how was the law broken if pre-signing consent forms does not mean failing to have a consultation with a woman?  Also, accepting that the D.O.H. just considered it to be ‘good practice’ for a medic to see a woman before an abortion, was this or is this happening at any frequency now in the UK? What happens to the woman? 

This is important as a two-doctor model is being proposed here in Ireland for abortions after 12 weeks, so mid-trimester 12 to 24 weeks. Depending on what the government are saying at any one time, this may also include the final trimester of pregnancy under conditions which may go beyond the scope of acting to save the life of the mother (which was always practiced in this country before the 2013 ‘Protection of Life during pregnancy act’) and beyond abortions to full term for so called ‘fatal foetal abnormalities’ which the government propose should have no upper limit in pregnancy i.e. to birth. 

The two biggest private providers B.P.A.S. and Marie Stopes U.K. account for almost 7/10 of the 185,000 annual abortions in the UK paid for by the N.H.S. (termed NHS contract), with the N.H.S. accounting for 3/10, no doubt done through G.P. referrals (Only 2% are done privately).(4)

If via B.P.A.S. or Marie Stopes, the first point of contact is a call to an abortion provider, usually a B.P.A.S.  or Marie Stopes call agent, who as that first point of contact, is trained to work to a script and need not have a medical background. According to the N.H.S. guide to abortion, (5) a woman may, if she wishes, see a trained counsellor.

If the decision for the abortion goes ahead, (with or without further counselling following that phone call), then a booking is made and at the abortion facility, it appears that the woman is seen by a nurse or doctor who obtain consent  as per N.H.S. guidelines. The abortion can be done / initiated the same day.

What becomes clear from studying some of the Quality Reports by the Care Quality Commission  / C.Q.C. watchdog, is that a nurse consents the patient, but a doctor must sign-off on the consent form for the overall procedure without ever having to see the patient prior to the abortion. The 67 doctors in 2012 appear to have broken the law by signing the consent before the nurses went through the form with the women.

On reading the Quality Report for B.P.A.S. Slough (6) by the C.Q.C. watchdog, in 2017, it’s clear that nurses or midwives consent the women. Equally a review of Marie Stopes’ practice (7) in February 2017 shows that: “A review of the provider’s abortion policy indicated that registered nurses could obtain consent providing they had attended consent training and had this competency signed off, by a clinical operations manager, a clinical team leader and/or a doctor”.

According to the B.P.A.S. report, paperwork would then be submitted to a doctor on site, who would assess the consent form and okay it / sign or be free to request more information. The ’67 act however stipulates that a second doctor must sign the consent form. The C.Q.C. report stated: “If a second doctor was available on site, they would review the information and similarly authorise the HSA1 (government abortion form that must be filled in) as the second doctor or decline and request further information. If a second doctor was not available on site, B.P.A.S. used the electronic central authorisation system to ensure information and the HSA1 form was accessible and signed by doctors located at other B.P.A.S. units.”

The second doctor must agree that the ground for abortion is the same as the first even if they are off-site in another clinic from the information in the consent form the nurse sends through. If >1 or different grounds are found for the abortion by both doctors they must liase and agree which ground the abortion is being authorised under.(8)

There does not appear to be any other necessity for two doctors to liaise.

Ann Furedi for abortion provider B.P.A.S. in that second Telegraph article on Dept. of Health guidelines was quoted as saying: “Recently, doctors providing abortion services have felt under intense political scrutiny, and this document should give them the reassurance that neither the law nor regulations have changed to accommodate those who think their work is wrong.  The law impedes best practice. There is no clinical need for two doctors to certify a woman’s reasons for abortion, in addition to obtaining her consent, it simply causes delays. B.P.A.S. trusts women to make responsible choices and B.P.A.S. doctors comply with the law.”

In one breath, Ann Furedi of B.P.A.S., stated that the law hadn’t changed but that it impeded best practice as there was no need for two doctors to certify reasons or obtain consent.

Also in the same Telegraph article on the Dept of Health guidelines, came a somewhat surreal contribution from Public Health Minister Jane Ellison who said: “This brings clarity to abortion care. Throughout its development we’ve worked closely with medical professional bodies and consulted the Crown Prosecution Service to provide clear guidance to clinicians about their roles and responsibilities under the law so that they can continue to provide the best possible care for women.”

Was this how the law was originally intended to be interpreted in 1967?

Further mandating of the zero doctor model masquerading as a two doctor model then came from the British Medical Association B.M.A. representing the medical profession itself which months later, in November 2014 issued its ‘Law and ethics of Abortion’ guide (9). In its introduction it states:

“The BMA has longstanding policy dating back to the 1970s and 80s supporting the Abortion Act 1967 as a practical and humane piece of legislation.” They outline the abortion act as follows:

Under the Act, a pregnancy can be lawfully terminated by a registered medical practitioner, in an NHS hospital or premises approved for this purpose, if two medical practitioners are of the opinion, formed in good faith……

This is then followed by the different grounds under the act.

It continues, “there is no legal requirement for the doctor to personally examine a woman seeking termination. Indeed, there is the option on the HSA1 (abortion) form for one or both of the doctors to certify that they have not seen or examined the woman. In 1981 the courts confirmed that abortion was a procedure carried out by a multi-disciplinary team, and that whilst the doctor should accept overall responsibility for all treatment with regard to a termination of pregnancy, they do not need to personally conduct every stage of the procedure, and can rely on information gathered by other members of their team in forming their opinion. Nevertheless, doctors must be satisfied that the conditions of the Abortion Act have been met.”

They cite the D.O.H. guidelines: “Guidance from the Department of Health asserts that it considers pre-signing of forms without subsequent consideration of any information relating to the woman to be incompatible with the requirements of the Abortion Act.23”

So there it is. The consent forms may not be pre-signed, but they must be post-signed where usually a nurse, not a doctor, has consented the woman and the doctors sign the form afterwards. At least by having the doctor take the responsibility for examining the completed consent form before signing off on it, it opens the possiblity of dialogue with the nurse about any issues that might have arisen when consenting her or even the option to see the woman herself, though there is no legal requirement to see her. In fact,  the official abortion forms give abortionists the option to document that they did or didn’t see the woman as it’s so accepted that they don’t need to.  With the 67 doctors guilty of pre-signing, it may have been tempting or thought implicitly okay, to just cut to the chase in a busy clinic and  pre-sign the form, trusting a nurse would later flag them if something came up. Though speculative, the fact that the 14 NHS trusts found guilty of pre-signing were found to be doing so after the Secretary of State for Health had sent all of the 249 U.K. locations where abortions are performed a reminder of what their duties are under the act, makes one question if the practice was even more widespread, as those found guilty it, had received fair warning from the Dept. of Health, which clearly flagged breaches must be happening.

One potential consequence of pre-signing is that is sooner or later something can go wrong somewhere and the whole practice is then brought into question. To ensure the buck stops with the doctor by getting them to sign off on the nurse’s consent, ensures that if something does go wrong, it is an individual case and the whole practice can continue.

Did Earl Howe who called for prosecution in the House of Lords and the cross-party M.P.s who went to the Metropolitan Police, know that the pre-signing of consent form scandal was only problematic because at stake was maintaining a real or perceived chain of clinical command?  Did they react because they believed at least one medic would see the woman before the operation?

The careful wording of a response by the G.M.C. would not debunk any misperception or false reassurance. Only the Dept. of Health statement did so, shedding light on the current loosest of  interpretations of the original 1967 act and in likelyhood, only to defend the practice and the doctors involved.  The government still insists that doctors oversee the process of screening carried out by nurses.

The doctors responsibility is to sign consent forms after nurses see the woman and hopefully pick up any red flags if they emerge.

For Ireland, the proposal by government here for two doctors to sign off on mid and possibly late trimester abortions must raise red flags too. As with all of its proposals, once the 8th is gone, it’s anyone’s guess on how the parliament / Dail would word legislation and how that would be interpreted over time.

Josephine Quintavalle of the campaign group, Comment on Reproductive Ethics, was quoted in the second Telegraph article on the Dept of Health guidelines on Skype / phone consultations: “A telephone consultation to ensure authorisation – presumably with a pro-choice doctor – completely ignores the life-taking nature of abortion, makes a complete mockery of the original Act and would surely not be tolerated in any other branch of medicine.”

Tomorrow’s post: 53 days to go…..

 

(1): https://www.telegraph.co.uk/news/uknews/law-and-order/10807990/Pre-signing-abortion-forms-is-illegal-General-Medical-Council-admits.html

(2): http://www.cqc.org.uk/news/releases/findings-termination-pregnancy-inspections-published

(3): https://www.telegraph.co.uk/news/health/news/10851574/Abortion-doctors-can-consult-women-on-phone-or-via-Skype-guidance.html

(4)https://www.gov.uk/government/statistics/report-on-abortion-statistics-in-england-and-wales-for-2016

(5) https://www.nhs.uk/conditions/abortion/what-happens/

(6): http://www.cqc.org.uk/sites/default/files/new_reports/AAAF9125.pdf / BPAS Slough Quality Report pg. 19, 23-24.

(7): https://www.cqc.org.uk/sites/default/files/new_reports/AAAG6589.pdfhttps://www.cqc.org.uk/sites/default/files/new_reports/AAAG6589.pdf   / Marie Stopes Interantional UK Quality Report 

(8): The law_and_ethics_of_abortion_BMA Views Nov 2014 pg. 6 : 2.1.4

(9): The law_and_ethics_of_abortion_BMA Views Nov 2014 pg. 3.

 

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