Friday, November 16, 2012

What does Savita Halappanavar's death mean?

[Today's guest post is by Irish SPL member Evelyn Fennelly.]

The case of Savita Halappanavar should cause anyone concerned about the well-being of women to be incensed. As a resident of Galway City, as a medical student, and as a pro-life activist, I’m appalled and deeply saddened by her case.

We cannot know all the details about her condition, treatment, and untimely death until the investigations are completed and the results made available to the public.  What we do know is that the standard medical practice, in conformity with Irish law and medical ethics, requires that pregnant women receive all essential medical treatment during pregnancy – even if it won’t be possible for the baby to survive that treatment.

The Irish Medical Council’s guidelines on professional conduct and ethics clearly state that “In current obstetrical practice, rare complications can arise where therapeutic intervention (including termination of a pregnancy) is required at a stage when, due to extreme immaturity of the baby, there may be little or no hope of the baby surviving. In these exceptional circumstances, it may be necessary to intervene to terminate the pregnancy to protect the life of the mother, while making every effort to preserve the life of the baby.”

In a piece in the Irish Independent, Galway lawyer Eilís Mulroy confirms that “The decision to induce labour early would be fully in compliance with the law and the current guidelines set out for doctors by the Irish Medical Council. Those guidelines allow interventions to treat women where necessary, even if that treatment indirectly results in the death to the baby. If they aren't being followed, laws about abortion won't change that. The issue then becomes about medical protocols being followed in hospitals and not about the absence of legal abortion in Ireland.”

Speaking to a government committee in 2001 as Chairman of the Institute of Obstetricians and Gynaecologists, Professor John Bonner said that "In current obstetrical practice, rare complications can arise where therapeutic intervention is required at a stage in pregnancy when there will be little or no prospect for the survival of the baby, due to extreme immaturity.” "In these exceptional situations failure to intervene may result in the death of both the mother and baby. We consider that there is a fundamental difference between abortion carried out with the intention of taking the life of the baby, for example for social reasons, and the unavoidable death of the baby resulting from essential treatment to protect the life of the mother." “We have never regarded these interventions as abortion. It would never cross an obstetrician's mind that intervening in a case of pre-eclampsia, cancer of the cervix or ectopic pregnancy is abortion. They are not abortion as far as the professional is concerned, these are medical treatments that are essential to save the life of the mother.”

Dr. Jen Gutner asks in her post whether Catholic law or malpractice killed Savita Halappanavar. She concludes that “the fact that a termination was delayed for any reason is malpractice.” and goes on to say that “There is no medically defensible position for not doing anything other than optimal pain control and hastening delivery by the safest means possible.” When asked to clarify if such treatment constituted abortion or delivery, she stated: “Delivery = empty the uterus either induction of labour of D&E”.

I agree that religious beliefs ought not cause doctors to withhold medically necessary treatment. To be fair, Catholic teaching allows for medical treatment of pregnant women, even if this treatment has the unintended, but unavoidable, side effect of fetal death. If anyone at University College Hospital Galway justified withholding a legal treatment (that was also permissible by the Catholic Church) on the assertion that “this is a Catholic country”, I suggest they read this, this, and this – and also get a new job.

This is a very serious case, and it should be investigated thoroughly. On Tuesday I sent 68 e-mails to management of the health service, to TDs, and to Senators, urging them to investigate this matter fully.

The treatment that Savita Halappanavar required was legal and permitted under the Medical Council guidelines. Why did the medical team not induce as they could have? Was the doctor able to make a correct diagnosis? Was the doctor capable of performing treatments in such scenarios?

These questions should be answered as part of the three investigations that have been launched into the matter. Hopefully these investigations will explain why medical staff at UCHG did not provide treatment for miscarriage, when such medical treatment is legal and standard practice in cases such as Mrs. Halappanavar's.

If the allegations that the medical team withheld treatment are true, I believe that we can expect the Medical Council to strike off the doctor(s) at the centre of the case. And doctors who withhold treatments and ignore the Council’s guidelines on best medical practice in such cases should be struck off the medical register.

The Medical Council is clear that in cases where the fetus is still alive, treatment is allowed even if “there is little of no hope of the baby surviving”. That she wasn’t treated is a failure of the hospital and medical team, not a problem with the law or with Medical Council guidelines. Necessary medical treatment during pregnancy, even if fetal death is inevitable, is legal in Ireland (and should remain so). In fact, it is standard medical procedure in cases like Savita Halappanavar’s to expediate delivery. She should not have been made to hang on for as long as she did – if the details that are being reported are correct, her case was grossly mismanaged.

It is possible that Savita Halappanavar would not have survived even if she had been given medical treatment when she first presented at the hospital, such was the severity of the infection. But she was entitled to be treated promptly, and she ought to have been treated promptly, and doing so would have greatly reduced her risk.

Miscarriage has never formed part of the abortion discussion in Ireland. Legalising abortion will not change the management of miscarriage. Miscarriage is a common and very sad event that is managed by doctors as a routine part of their obstetric practice. About 14,000 women in Ireland experience miscarriage every year. Half of them attend hospital for treatment. Our laws on abortion do not prevent physicians from treating these 7,000 women in whatever way is necessary. It is misleading to suggest that Ireland's law on abortion is in any way responsible for Savita Halappanavar’s death. The Medical Council is clear that treatments managing miscarriage are permitted, and they do not constitute abortion.

The shameless opportunism of these groups and individuals is especially appalling when their reaction is contrasted with stories of women in the recent past that didn't fit with their agenda.

Pro-choice groups were totally silent when counsellors at the taxpayer-funded Irish affiliate of Planned Parenthood were found to be giving women life-endangering advice regarding abortion.

These groups and individuals have a track record of either ignoring or castigating Women Hurt, a group of women who have suffered mental and/or physical consequences following their abortions. Astoundingly, the National Women’s Council of Ireland just last year launched an attack on Women Hurt. It’s absolutely outrageous that a state-funded women’s organisation would attack women who seek to share their stories of healing.

They are silent on the issue of forced abortion in China, when women as far along as the third trimester are forcibly removed from their homes and subjected to abortions and sterilisations against their will.

Obstetric excellence is what saves women’s lives, not abortion. The greatest thing any of us can do to honour Savita Halappanavar’s life is to insist on obstetric excellence for every woman. 

I received an e-mail today from a friend who experienced a late term miscarriage a few years ago and required treatment in hospital. She spoke of how “hurt and angry” she has felt over the past few days, seeing the tragic case of Mrs. Halappanavar being used to advocate a change in abortion law. My friend agreed that Savita “should have got any care necessary to save her life” and she knows that this care wouldn’t have constituted abortion. She knows that the treatment she received when having her own miscarriage wasn’t an abortion, and is deeply hurt that pro-choice groups are attempting to imply that management of miscarriage is abortion. She spoke of the “hurt and pain of a miscarriage” being exacerbated by pro-choice advocates who are using losses like hers to advocate for abortion.

Pro-choice claims of being pro-woman ring hollow when they exploit the sorrow of grieving mothers like my friend to advance legislation. It's reprehensible that pro-choice groups and individuals are using this case to forward their political agenda to see abortion legalised in Ireland, when management of miscarriage is not abortion - medically or legally. I understand, and can forgive, well-meaning members of the public reading the reportage in the last few days and being misled. But I find it deeply disturbing that pro-choice groups and individuals who are informed on this matter are misrepresenting the medicolegal situation by claiming that this is a problem with the law when this is a case of medical negligence - the law and the Medical Council guidelines are very clear that management of miscarriage is not abortion and it is not prohibited by law.

They refuse to condemn gendercide in India and China, where abortion and infanticide have resulted in 200 million girls missing from our world today. 

Pro-choice groups didn’t care about those women then, and they don’t really care about them now. They’re only interested in Savita Halappanavar now that they can use her as a political football to advocate the legalisation of abortion. That is deeply disingenuous behaviour from people who consider themselves to be pro-woman.
Leading OB/GYNs speaking in the media today reiterated that Savita Halappanavar’s case was not about abortion laws. While they would welcome further clarity in the law, all medical treatments pregnant women need are provided for them within the law and under the Medical Council’s guidelines. Pro-life groups would support a Bill to reinforce the Medical Council guidelines of providing all necessary medical treatments to mothers during pregnancy. Focus on the mother’s health and minimisation of infection risk are both key in the management of miscarriage. This care is not affected or limited by a ban on abortion. Prof. Fionnuala McAuliffe, spokesperson for the Irish Institute of Obstetricians and Gynaecologists confirmed that doctors are allowed under the law and under Medical Council guidelines to treat women during pregnancy, even if the fetus will not survive. She also said that "the outcomes for pregnant women in Ireland are among the best in the world. We have excellent maternity services. There is no evidence that we are letting patients die to prolong the pregnancy."

People are right to be outraged at what happened to Mrs. Halappanavar. But that outrage ought to be directed at the mismanagement of her care, not at a law that permits the treatment she should have received. 


Béatrice Fedor said...

Thank you Evelyn for writing this article.

JoAnna Wahlund said...

Thank you, Evelyn. This is an excellent analysis.

Now, I am not a medical professional, but I am a woman who has given birth four times and has miscarried twice. All of my births have been drug-free and have taken place in a hospital, and I've done extensive research on childbirth and delivery so that I could be a better advocate for myself while in the hospital.

What I find absolutely appalling is that Savita was apparently admitted on Sunday with a leaking amniotic fluid sac and a dilated cervix, but antibiotics were not started until Tuesday even though she was showing signs of a possible infection. In my experience, a woman in America presenting at a hospital in her condition with those symptoms would have been started on antibiotics to prevent and/or fight infection pretty much immediately. At the very least, they would have immediately run tests on the amniotic fluid to determine if an infection was present. It seems to me, based on the facts available, that Savita's death was due to extreme medical mismanagement of her infection, not abortion laws.

Clinton Wilcox said...

That's pretty much my understanding, as well. Her death was not a result of "lack of abortion," but a failure to give her antibiotics right away. If she had, then both mother and child likely could have been saved. So it was still a case of medical mismanagement, but not in the way that pro-abortion advocates are exploiting it to be.

Maidrin Ruadh said...

"On Tuesday I sent 68 e-mails to management of the health service, to TDs, and to Senators, urging them to investigate this matter fully." Just to clarify for those unfamiliar with the Irish political systems, a TD is a member of the lower house of parliament and a Senator is a member of the upper house of parliament

Maidrin Ruadh said...

An Indian doctor's perspective

TooManyJens said...

Hi Evelyn,

Thank you for the great post, and I will be linking to it. Just a heads-up: the first "this" link, where you're talking about double effect, is broken.

Kelsey said...

Good catch-- fixed!

TooManyJens said...


TooManyJens said...

"Our laws on abortion do
not prevent physicians from treating these 7,000 women in whatever way is

Do you know of any statistics on how many of those 7,000 women require terminations to prevent infection? I'm trying to figure out if this is something other hospitals have figured out that they can legally do, and if so, what the issue was with this one hospital.

I'm reading a lot about how the issue is legally murky and the doctors may have been afraid that they would face jail time, which seems to be contradicted by the Medical Council's guidelines and what OB/GYNs have been saying in the media, but I am not close enough to the situation to know what accounts to trust, who has which axe to grind, etc.

VAliberalprochoiceDEMOCRAT said...

For some people, this story would cause them to question the validity of their own beliefs. These sorts of people would renounce their "pro-life" beliefs. Others will simply ignore what happened here, and these people will continue to hold "pro-life" beliefs regardless of the consequences. How many more pregnant women need to die from having medical care denied to them by "pro life" people?

Clinton Wilcox said...

Actually, pro-abortion journalists have been running with this story before all the information was known. They were shamelessly using this tragedy to further their own agenda. The reality is she did not die due to "lack of abortion," she died due to lack of antibiotics. If she had been given those, both mother and child would likely still be with us. So there was medical negligence, just not of the kind pro-abortion journalists would have us believe.

jacques said...

Say the doctor had deliberately killed the fetus as soon as Savita presented, despite it having a heartbeat and before infection would have set in.
The Medical Council guidelines come into play for fitness to practice/striking off hearings. They are not law.
Our hypothetical doctor would have committed a crime under the 1861 Offences against the Person Act. I know of no legislation that would protect them.

Tracy Joynes said...

We have designed a new website because the voices of women need to be heard. We support good pre and post natal care for all women everywhere in the world. There is more than enough money to be able to fund excellent care for every woman and her baby. I am sorry to hear of any death connected with pregnancy, death is always a painful and life changing experience.

Anne said...

But we have still to wait to hear what the doctors and consultants who were there have to say. We have only heard one side of this. I find it very hard to believe that a Consultant or doctor would bring religion into the situation and say 'this is a Catholic country'. Sounds bizarre.

Anonymous said...

It appears that beautiful Savita may have had ESBL which is resistant to antibiotics -

Dr Clair is up to date in the research - i.e. when he said, "This insult is further compounded by the fact the Indian subcontinent has played a major role in the spread of ESBL positive organism". It seems that ESBL appears more prevalent in the Indian people genetically -

Supporting these data, the SMART study showed remarkably high background rates of 79% ESBL

Abstract from Another study -
Foreign Travel Is a Major Risk Factor for Colonization with Escherichia coli Producing CTX-M-Type Extended-Spectrum β-Lactamases: a Prospective Study with Swedish Volunteers
Thomas Tängdén,1,* Otto Cars,1 Åsa Melhus,2,† and Elisabeth Löwdin1,†
Sections of Infectious Diseases,1 Clinical Bacteriology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden

Participants visiting India were most likely to acquire ESBL-producing strains. Despite the small number of travelers to India, this was highly statistically significant, and previous studies also pointed out that visits to India in particular appear to be a risk factor for infection with ESBL-producing E. coli (8, 15). Although not statistically significant, travel to other countries in Asia and the Middle East was also associated with a higher risk of colonization by ESBL-producing strains (32 and 29%, respectively) in our study, which might well reflect the rates of ESBL production and fecal colonization in the countries visited (9, 11, 18, 32).

Tuesday, November 20, 2012

Concerning the unfortunate death of Savita Halappanavar, I fear that
the main problem is being missed.

The Irish media reported last week that this young woman most likely
died from sepicaemia due to an ESBL E. coli strain.

ESBL, or Extended
Spectrum Beta-Lactamase positive gram negative bacteria, are now
spreading rapidly within the Irish population.

The significance of
these organisms is in the fact that they are resistant to almost all
available antibiotics.

We had a media frenzy over the last decade about MRSA but we had at
least ten antibiotics capable of inhibiting this organism.

In contrast we have only a few antibiotics (if we are
lucky) active against ESBL positive organisms, and these are third
line antibiotics which must be used sparingly.

Deaths have already
occurred due to these organisms and the potential for many more deaths
is very real. ESBL positive organisms present a far greater threat
than MRSA ever did or will.

I feel confident that the doctors in
Galway would have followed accepted procedures for dealing with the
clinical problems that emerged. When signs of infection first develop,
doctors are usually forced to used antibiotics blindly, often with
broad spectrum intravenous antibiotics.

The problem with ESBL
organisms is that they are very resistant and thus a tragedy can result.

It appears to me that the problem was an unforeseen ESBL infection
rather than an issue of obstetric mishandling.

In my
experience of over 30 years with clinical antibiotic use, ESBL
antibiotic resistance is by far the most worrying development that I
have experienced.

The insult to the Irish medical service is added to by the suggestion
that the Indian Embassy is upset with the lack of abortion services in
Ireland .

This insult is further compounded by
the fact the Indian subcontinent has played a major role in the spread
of ESBL positive organisms.

If the Minister for Health wants to
preserve lives, young and old he would do better to put a lot more
resources into monitoring and controlling the spread of ESBL positive
bacteria rather than responding to a pressure group who obviously have
an ambition to turn our superb obstetricians into little more than
paid killers.

Dr J Clair
Co Cork . EXAMINER. NOV.20


I've read your post "What does Savita Halappanavar's death mean". It's such a worthy writing!

Jasper Alistair
Medical Negligence Solicitors London