The issue of suicidal intent as grounds for granting an abortion is extremely contentious. A number of commentators, including some Fine Gael TDs and Senators say they fear inclusion of suicide risk as grounds for abortion could " . . . open the floodgates". Others differ.
Dr Rhona Mahony, Master of the National Maternity Hospital, noted: " . . . as a woman, that I'm offended by some of the pejorative and judgmental views that women will manipulate doctors in order to obtain termination of pregnancy, on the basis of fabricated ideas of suicide ideation or intent".
She also went on to say: "There also seems to be an assumption that psychiatrists are unable to assess the issue of suicide ideation, something they do every day in their clinical practice." (Joint Committee on Health and Children, public hearings on report re A, B, & C v Ireland (2013)).
These stated beliefs provoke the questions of whether people really feign suicidal intent, how do psychiatrists assess risk of suicidal behaviour and if someone were to attempt to feign suicidal intent, would psychiatrists be able to detect this?
So do people feign suicidal ideation in general psychiatric practice? The answer is yes – regularly. A frequent situation for any psychiatrist is a patient who states he/she has suicidal intent, but it may be suspected that this is not really the case. This may be an attempt at deception – straightforward malingering is not uncommon where a person is trying to avoid legal difficulties or looking for accommodation in hospital. More often there is a less conscious desire to deceive. But the patient has learned to communicate distress in a shorthand form for them by expressing intent to gain access to care that may otherwise be lacking.
Psychiatrists are well trained in determining risk of suicidal behaviour. They do this solely by taking a full history from the patient and any informants available.
Mood disorders
Psychiatric history of any major mental disorders (especially mood disorders and substance misuse) is important, as are history of previous suicide attempts, upbringing, medical history and current supports and stressors. The patient is asked directly about his/her mood, views of the future, hopelessness, passive death wish and then whether they have contemplated harming/killing themselves. If they have, questions are then directed to the severity and elaborateness of these thoughts/planning: what method, any final acts (such as making a note or will), have they begun preparations? Other sociodemographic factors are taken into account, eg older age, male sex, divorced status etc.
Despite training and experience, psychiatrists can’t always detect feigned suicidality. Assessing risk of suicide is an example of a test that has high sensitivity and low specificity. In other words, this process is reasonably good at picking up those assessed who may be suicidal (not all – some conceal symptoms). But it is not good at picking only those who will act on suicidal impulses. This means that while the majority of those at risk of completing suicide will be identified, a large number who will not complete suicide are also so identified (false positives). Psychiatrists are also extremely dependent upon what the patient tells them. Unless collateral history, history inconsistencies or previous knowledge of the patient indicate otherwise, the patient’s account has to be taken at face value. The situation arises, not infrequently, that a patient is admitted only to find after a short period there is little evidence of suicidality.
The question thus arises: does this mean women could or would feign suicidal ideation in order to obtain an abortion under the proposed legislation? As to “could”– yes, but “would?” I don’t know. Even assessment by two psychiatrists does not necessarily provide the protection against unnecessary abortion it appears to provide as all psychiatrists use the same method of identifying suicide risk – with high sensitivity and low specificity. The question of whether any woman would feign symptoms in this situation is difficult. One would hope the gravity of the situation, literally the life and death circumstance for the foetus, would mean no woman would. But this is a situation where the individual’s ethical view on the status of the foetus comes into play. If the foetus is not seen as a person (or not yet) by the individual, this may lessen the deterrence from such actions.
This uncertainty in assessing suicidal behaviour may not seem to matter depending on your view of the foetus. However, this uncertainty must be considered in conjunction with what treatments are indicated. It has been repeatedly stated in the debate that “abortion is not a treatment” for suicidality. While this is true, removing stressors is an accepted treatment strategy in conditions such as depression. But often the stressors can’t be easily removed – for example bereavement, divorce or debt.
Effective psychotherapy
In these situations we are still able to provide treatment – identification of particular stressors is essential for effective psychotherapy. The ethical dilemma that arises is: if we are to take the Constitution's position of having equal regard for the life of the mother and the unborn, can we see the foetus as a stressor capable of being eliminated when we have evidenced-based alternative treatments available to treat the mother?
Another concern that can interact with this uncertainty in suicidal behaviour assessment is the pervasive influence of defensive medicine. Put simply, in an area of uncertainty such as risk, with all options being equal, doctors will often go for the option that is safest medico-legally. This will favour the mother over the unborn disproportionally since successful litigation is unlikely to arise from any harm to the latter.
Dr Michael Reilly is a consultant psychiatrist. He spent two years as a research fellow in suicidology and has a special interest in psychiatric ethics.