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This is Part One of a series of diaries exploring the issues surrounding the death of Savita Halappanavar, a 34 year old woman who died in an Irish hospital after suffering a miscarriage.  Her story has sparked heated debate about abortion laws, both in Ireland and in the U.S.

I will apply, for the benefit of the sick, all measures that are required....

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty...

The Hippocratic Oath (Modern Version).  Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University.

The day Praveen Halappanavar took his pregnant wife, Savita, to University College Hospital Galway because she was bleeding from a miscarriage, he knew the chances of losing his unborn child were high.  But he never dreamed that he would lose the love of his life too in the terrible course of events that occurred the next few days.  The world has watched and learned in horror as circumstances surrounding Savita’s death emerge.  Her husband has described how he held his wife’s hand as she died from blood poisoning after Irish doctors refused to perform an abortion. Praveen said that he begged doctors to carry out the procedure, but they refused to do so because she was ‘in a Catholic country’ and the fetus’s heartbeat was still present.

Many critics have blamed Catholic Ireland’s “pro-life” abortion policies, but upon closer examination, it is becoming more apparent that medical malpractice in the name of “forced birth” fundamentalism (a term coined by TrueBlueMajority) may have been the cause.  Although we don’t yet know all the details about her condition, treatment, and untimely death until the investigations are completed, we do know that 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, the regulator of the medical profession in Ireland, maintains the register of medical practitioners and has the power to place restrictions on or revoke licenses in cases of questions about a doctor's ability to practice. Their objective is to protect the public by promoting and better ensuring high standards of professional conduct and professional education, training and competence among registered medical practitioners.  Their Code of Ethics clearly and succinctly states:

  “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 the Savita’s situation, the guidelines to allow intervention were in place.  In the opinion of Eilis Mulroy,"if these guidelines 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."   Professor John Bonnar, then chairman of the Institute of Obstetricians and Gynaecologists, spoke about the matter to the All Party Oireachtas Committee's Fifth Report on Abortion, saying: "In current obstetrical practice, rare complications can arise where therapeutic intervention is required……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."

According to earlier reports in the media, as Savita’s infection from miscarriage developed and increased, she was in so much pain that she begged doctors to perform a surgical uterine evacuation (ERPC).  This was the time that her doctors told her that ‘this is a Catholic country’, and would not perform the procedure.  And yet, the Clinical Practical Guideline for Management of Miscarriage in Early Pregnancy, published by the Institute of Obstetricians and Gynecologists of the Royal College of Physicians of Ireland, clearly states:

“Surgical uterine evacuation (ERPC) should be offered to women that prefer that option. Clinical indications for offering ERPC include persistent excessive bleeding, haemodynamic instability, evidence of infected retained tissue and suspected gestational trophoblastic disease.”

Dr. Jen Gunter, a Canadian-born OB-GYN and pain physician, wrote in her blog

As there is no medically acceptable scenario at 17 weeks where a woman is miscarrying AND is denied a termination, there can only be three plausible explanations for Ms. Hapappanavar’s “medical care”:

1) Irish law does indeed treat pregnant women as second class citizens and denies them appropriate medical care. The medical team was following the law to avoid criminal prosecution.

2) Irish law does not deny women the care they need; however, a zealous individual doctor or hospital administrator interpreted Catholic doctrine in such a way that a pregnant woman’s medical care was somehow irrelevant and superceded by heart tones of a 17 weeks fetus that could never be viable.

3) Irish law allows abortions for women when medically necessary, but the doctors involved were negligent in that they could not diagnose infection when it was so obviously present, did not know the treatment, or were not competent enough to carry out the treatment.

Not only do I know these scenarios backwards and forwards as an OB/GYN, I had ruptured membranes in my own pregnancy at 22 weeks, a rescue cerclage, and then sepsis. I know how bad it can be.

As the mother of two physicians, I am usually on the defensive side of medical practice.  I know first-hand the emotional and physical toll that the training and practice of medicine takes on an individual.  Yes, there are always some who do it for the power, the money, and the self-esteem.  But I will also tell you that most people go into medicine because they truly feel called to take care of the sick.  There is a universal ‘band of brotherhood’ between doctors and they protect their own.  It is a means of survival.   That is why it is so hard to understand how Savita could have died in the care of those dedicated and devoted to the practice of healing.
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