Examination of Witnesses (Questions 160-179)
DR VINCENT
ARGENT, DR
TONY CALLAND,
LIZ DAVIES
AND KATHY
FRENCH
17 OCTOBER 2007
Q160 Chairman: He is actually responding
on behalf of the BMA in terms of whether there is a scientific
basis on which two doctors' signatures are required. That is the
basis of the inquiry. I am trying to stick to that because if
we move into ethics, we will be all over the place. Liz, what
do you feel in terms of why we need two doctors in terms of the
health of patients?
Liz Davies: We certainly do not
need two doctors' signatures to give women permission to have
an abortion. Women are quite capable of making this decision.
They do not need to be saved from themselves. At Marie Stopes
we certainly have always advocated that the necessity for two
signatures should be removed, at least in the first trimester.
I cannot agree that two signatures are necessary in later abortions,
purely because I think as long as the woman is being given full
information regarding the risks of any procedures she undertakes,
again she is quite capable of making that decision for herself.
The reasons for women seeking an abortion in the later stages
we see as equally valid to those in the early stages and so I
see no difference between early and late abortion from that point
of view.
Kathy French: I think the two
doctors' signatures made a lot of sense in 1967. We have moved
on from there. For the autonomous individual, the need for two
signatures is very cumbersome. It puts a huge burden on women
when somebody cannot sign the signature. I do not think we need
it in current practice.
Q161 Chairman: Is that at any time
during either the first or second trimester?
Kathy French: I am not sure about
the second trimester. I think two signatures is again excessive.
There may be a need certainly one and that is about discussion
with the woman and the doctor who is caring for her.
Q162 Chairman: Dr Argent, in terms
of the HSA1 form, is there any evidence that signing it without
seeing the patient first is putting the patient's health at risk?
Dr Argent: I am not sure there
is any published evidence that addresses that particular factor.
I have to say the practice of obtaining signatures in some units
is somewhat variable. This has not been written up very much in
journalism because obviously people would not like to talk about
it.
Q163 Mrs Dorries: Dr Argent, what
proof do you have then to make that claim?
Dr Argent: It is what I have observed
over many years of practice in abortion services.
Q164 Mrs Dorries: So it is anecdotal
evidence then?
Dr Argent: Yes.
Q165 Mrs Dorries: It is not scientific?
Dr Argent: Yes.
Q166 Chairman: I am really quite
anxious about this issue of doctors' signatures and the health
of patients because we should have evidence of that. Is there
any evidence at all to say that having two doctors' signatures
actually improves the health outcomes of patients who are presenting
for abortion?
Dr Argent: I am not aware of any
evidence that suggests that. Indeed, in many cases of course it
does actually say in HSA1 form that the doctor has seen or not
seen and examined the patient and sometimes the clinician does
not actually see the client for a consultation. They sign the
form on the basis of reading the clinical notes.
Q167 Chairman: The RCOG said that
that is an acceptable practice?
Dr Argent: It would appear to
be acceptable, yes. It has been discussed by academic lawyers.
It does not state that in the Abortion Act itself but because
of the wording of the HSA1 form, it is accepted.
Q168 Chairman: It went to the House
of Lords and the House of Lords supported the RCOG in that. Are
they all wrong, in your view?
Dr Argent: Academic lawyers look
at the question of how a doctor forms an opinion in good faith
that the abortion becomes eligible under the terms of the Act.
Some would say it is difficult to form that opinion if you do
not discuss the situation with the client. Others would say that
they are supportive of women's choice and therefore that of its
own is sufficient.
Q169 Dr Harris: Continuing that point,
is it your view that if a doctor is of the view that if a woman
wants an abortion and it is early enough so that it is clear that,
all other things being equal, it is going to be less risky for
her to have the abortion than continue the pregnancy—full
stop—even without her motivation, that would be a common
reason for such a signing on Ground C, I think, in good faith?
Is that a reasonable suggestion?
Dr Argent: Yes, I think many medical
colleagues and other health care professionals would take the
view that if they believe that, that is sufficient to justify
an abortion under Ground C.
Q170 Dr Harris: Dr Calland, you will
be aware that although I am on your committee I took no part in
the formulation of your evidence to this inquiry. I want to ask
you about the issue of two doctors in the second trimester. My
understanding is that the BMA just has not taken a view on the
second trimester. The Royal College has said that they can understand
the need for a second clinical opinion as good practice in complex
case perhaps of foetal abnormality. Could you explain whether
you think that the need for a second opinion, which is good clinical
practice, is separate from a statutory requirement to have two
doctors' signatures on a form?
Dr Calland: All I can do is reiterate
BMA policy, which really is around the first trimester. I think
it would be logical that where risk was increasing, it would be
of benefit to have two signatures rather than one. The BMA position
is quite clear about the first trimester. We do not consider the
risks there are significant enough to warrant two signatures and
therefore that is the position we have taken.
Q171 Dr Harris: I am just asking
whether it is better to have a second opinion—i.e. someone
seeing the patient in a formal second opinion way—as opposed
to just a second signature on a form "patient unseen"?
Dr Calland: I do not think the
BMA has a position on that.
Q172 Mrs Dorries: I have a question
to Dr Argent and then one to Tony Calland. Dr Argent, you are
claiming anecdotally that every day doctors up and down the country
are breaking the law because it is a legal requirement that two
doctors sign the signature, one would hope after having both seen
and consulted with the patient. You are telling us that doctors
every day break the law by carrying out this procedure. The reason
why we have two doctors' signatures is that this is not like going
to have your appendix out or your tonsils out where you go to
a doctor and you are informed of what is going to happen at the
operation and then a doctor signs. This is actually taking a life.
Are the two signatures not a requirement to protect the doctors
also as well as the patient, given that we are talking about ending
a life in abortion, not a procedure?
Dr Argent: No, I am not saying
that doctors are breaking the law. What I am saying is that there
is a lack of clarity in the legal situation—
Q173 Mrs Dorries: I am sorry, you
said many doctors are not even signing the form—they are
just reading the clinical notes I think you said—until after
the abortion has even taken place. Is that not breaking the law?
Dr Argent: It is a legal requirement
to have two signatures on the HSA1 form before the abortion is
performed but in a small number of cases sometimes it is almost
actually signed in the operating theatre by the surgeon with the
patient anaesthetised on the table.
Q174 Mrs Dorries: It has gone from
being anecdotal in your observation up and down the country to—
Dr Argent: That is not necessarily
illegal because academic lawyers do disagree on the interpretation
of the Abortion Act. I think that some academic lawyers do agree
that the Abortion Act is badly drafted and many of these situations
are unclear.
Q175 Chairman: Rather than pursue
this, would you agree therefore, Dr Argent, and certainly Dr Calland,
that there is a requirement in fact for the law to be clarified
in this area? Is that what you are saying?
Dr Argent: It would be helpful
if there were clearer guidelines about such matters as whether
the clinician or the health care professional actually needs to
see the client and discuss the situation before signing the form.
It would appear the logic at the moment is that they do not have
to do that.
Q176 Chairman: On the two doctors,
before we leave this point, could you tell us, Dr Calland, why
in the BMA's view this is the only procedure where two doctor's
signatures are required. Why this and not anything else? If you
could take somebody's lungs out and replace them or take their
heart out and replace it, you do not need two doctors' signatures,
but for this procedure you do. What is so special about it?
Dr Calland: You are talking about
second trimester and beyond?
Q177 Chairman: The law as it stands
at the moment says that you need two signatures.
Dr Calland: It does. One would
have to second-guess what was in the mind of Parliament in 1967
as to why two doctors' signatures were there. We could probably
spend all morning trying to do that. I am sorry to repeat myself.
All I would say is that because of the risk issue, the BMA feels
that the first trimester is now such a low risk, particularly
with medical abortion, that we do not need two signatures to do
that. We feel that because the risk increases as you go through
into second trimester abortion and later where they take place,
it is not unreasonable to maintain the status quo for whatever
the reasons were.
Q178 Graham Stringer: Why is risk
the issue? A heart-lung transplant is much riskier than a second
trimester abortion. Why are you relying on risk?
Dr Calland: It is because we have
done. That is the argument that the BMA has used.
Q179 Mrs Dorries: I say to Dr Calland
that I would suggest it is because this is about ending a life.
Dr Calland, could you confirm: the Ethics Committee of the BMA
took its position after a vote at a recent conference that you
held. Motions were put to the floor; you took your vote and this
is where your position came from. Could you confirm that on that
day only pro-choice motions were put to the floor to be voted
on?
Dr Calland: I think you have been
in correspondence with the BMA on this issue and you have had
it clarified how the BMA conference works.
Mrs Dorries: I have. However, that does
not change the facts, does it?
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