'They are our hospitals'

Why the culture war over abortion is still being fought

Watching Irish political history unfold is pretty boring. Last November, a bill to legalise abortion for the first time in the history of the state was inching its way through the Oireachtas at a painfully slow pace. 

Journalists and politicians spent endless hours in the stale air and harsh lighting of the committee rooms which sit in the basement beneath the national parliament as the bill edged closer to becoming law. 

Sometimes sympathetic TDs would pass illicit chocolate bars to unfortunate reporters who had to stay and cover proceedings until the bitter end. Once there was a salacious rumour that a politician had thrown a bit of gin into their coffee cup to try to cope with the endless rows after one particularly long session.  

The process of passing the new abortion law got so mind-numbingly tedious that even the magnitude of what was happening had started to get boring. That’s why it was barely noticed when Peadar Tóibín, the Meath West TD, dropped an absolute bombshell in the middle of Committee Room 4 on November 7.

Mr Tóibín was defending the rights of anti-abortion doctors to be totally exempt from providing abortion services when he casually revealed that Kilkenny, Letterkenny and Cavan hospitals “would not participate in the government's planned abortion provision.” 

Simon Harris, the health minister, looked dubious. He told Mr Tóibín that the TD needed to be “very careful” about speaking on behalf of three maternity units. 

“I’m the health minister, and I haven’t received any advice that those three hospitals are not in a position to provide abortion services,” Mr Harris said. 

“As of yet,” Mr Tóibín said. 

Similar claims about hospitals refusing to provide abortion services were made in 2013, when Ireland legislated to legalise abortion when the woman’s life is at risk. Those claims never materalised, but some of Mr Tóibín’s have. 

Cavan and Kilkenny hospitals are not yet providing abortion services. Documents released to both JOE and TheJournal.ie under Freedom of Information redacted the reasons why, but the same documents revealed that it was conscientious objection which was blocking the introduction of abortion services in Letterkenny University Hospital. The same reason was given for the lack of early abortion services at Wexford general hospital. Documents also suggested that conscientious objection was blocking the introduction of services at Sligo University Hospital, and more recent letters suggested that more staff would need to be hired before abortion services would be available. 

The HSE first started talking to hospitals about providing legal abortion services last August, three months after the referendum. Mr Tóibín was the first person to publicly claim that specific hospitals would refuse to provide abortion services, but by December there were already rumours that some hospitals would be unable to provide abortion services because of conscientious objection.

Ahead of January 1, when abortion up to 12 weeks’ would became legal in Ireland, GPs who wanted to help provide the service had heard the same rumours. While local doctors can provide a legal abortion through pills to any woman who is less than 9 weeks’ pregnant, they need to refer her to a local hospital if she is between 9 and 12 weeks’ pregnant. Some GPs told reporters that they were anxious that they wouldn’t know which hospitals that they could refer a woman to, at a time when she would be close to missing the legal 12 week limit and not being able to access a legal termination in Ireland at all. 

Journalists who followed up on the rumours of conscientious objection issues with senior sources last December were dismissed, but one source admitted to JOE this week that there had always been “little hope” of getting legal and medical abortions in Letterkenny General hospital because the relevant staff had made it so clear that they were totally against abortion. 

Under a longstanding principle, every doctor has the right to refuse to perform a health procedure if it goes against their personal beliefs. Some smaller maternity units in Ireland might only have three or four obstetricians. If all of them conscientiously object to abortion, then the entire hospital can’t provide abortion services. 

This is a major problem for the Irish government, which is absolutely insisting that abortion must be available in all 19 of Ireland’s maternity units. Both Simon Harris and Leo Varadkar have repeatedly said that while individual doctors can opt-out of providing abortion services, entire institutions - meaning publicly funded hospitals - can’t. Senior sources also said they believed that the hospitals which are providing abortion services would be put under extra pressure if they were forced to look after women referred from hospitals where abortion services aren’t available. 

Ireland has one of the lowest numbers of obstetricians and gynaecologists per 100,000 people in the OECD, so it may not be easy to try to recruit extra obstetricians to work hospitals where all of the rest of the relevant staff are anti-abortion. Earlier this year, a job advert for an obstetrician at the National Maternity Hospital caused outrage among anti-abortion activists after it specified that applicants would have to be willing to provide termination of pregnancy services. Those who wanted to keep the Eighth Amendment used it to claim that the government is making the Irish health service a hostile place for healthcare workers who are pro-life. 

The government would flatly reject this, but in recent months the frustration from those trying to guarantee nationwide abortion access has started to show. Speaking at an event in April to mark the leaders of the Together for Yes campaign being included in the TIME 100 list, Peter Boylan, the leading obstetrician who was tasked with helping the HSE introduce abortion services, criticised some of his colleagues for being “reluctant” to provide terminations. 

“I think general practitioner colleagues deserve an awful lot of credit for stepping up to the plate, in some instances a lot more credit than some of my hospital colleagues — some of whom are being quite reluctant to introduce the service,” Mr Boylan said.

Since March, increasingly terse letters have been exchanged between the Department of Health and the HSE over the nine maternity units which still aren’t providing abortions between 9 and 12 weeks. 

Joan Regan, the department’s principal officer for acute hospitals policy, wrote to the HSE in March and said it was “important”  that having all 19 units providing abortions between 9 and 12 weeks is “achieved quickly.” In response, the HSE explained - not for the first time - that there were no plans to provide abortion services in South Tipperary General Hospital, because of the low birth rate in the hospital’s catchment area and “identified limitations” with resources. The HSE also said that there were no plans to have abortion services at Portiuncula University Hospital, based on a 2018 report into maternity services at the hospital which said that “complex work” at PUH should take place at Galway University Hospital instead. 

In another letter in April, the HSE also said that University Hospital Kerry was still facing the problem of not having a Director of Midwifery and could not provide abortion services yet. The HSE said that Midlands Regional Hospital Portlaoise was not providing abortion services itself, and instead referring women to the Coombe in Dublin. Most of the reasons for not having abortion services at Sligo University Hospital were redacted, but it was suggested it is not likely to be able to provide abortion services until the end of the year after hiring more staff. In letters to the department late last year, the HSE had said that staff at Sligo University Hospital were conscientious objectors. 

The reasons for a lack of abortion services at Cavan General Hospital and St Luke’s hospital in Kilkenny were redacted. Letterkenny General Hospital and Wexford General Hospital are both unable to provide abortion services because staff are conscientiously objecting. 

Internal Department of Health documents show that its official position was that it was “extremely disappointed” that there were still only 10 hospitals providing abortion services. Staff suggested getting Simon Harris to write to the head of the HSE, and put it under pressure to have abortion services at all 19 maternity units by September 1. A letter from the secretary general of the Department of Health to the HSE at the end of April again expressed disappointment and said that it was “government policy to normalise termination of pregnancy service provision within our maternity hospitals and that services will be provided in all 19 maternity hospitals/units to ensure appropriate geographic coverage across all areas of the country.” 

The department told the HSE that Simon Harris wanted to meet to discuss the issue on May 2. The minister’s speaking notes for the meeting, which have been seen by JOE, show that he told the HSE that “a woman should be able to have a termination at her local maternity hospital, if that is what she wants.”

“By introducing such services in this country, my expectation is that women will be spared the need to travel lengthy distances to access a termination,” Mr Harris’ notes said. 

“Therefore, I cannot stand over a situation where women have to travel long distances, for example from Donegal to Dublin, to get a termination.” 

In countries where abortion is legal, many anti-abortion activists concentrate their efforts on ensuring doctors can’t or won’t provide terminations. It’s a common tactic among big anti-abortion groups in the United States, which Irish anti-abortion groups regularly borrow tactics from. 

As soon as Irish anti-abortion advocates lost the referendum, they quickly rallied behind new messaging to try to protect anti-abortion doctors. Doctors who conscientiously object to providing abortion services have to refer the woman on to a doctor who will. Anti-abortion activists wanted the requirement to refer dropped, and there were also calls for entire hospitals to be able to object. The same anti-abortion groups are also preparing to fight government plans to ban protests and vigils outside hospitals and clinics providing abortion services.   

Now that it’s legal in Ireland, abortion rights aren’t being fought within the constitution or the walls of Leinster House but inside our health service.