Fearing prosecution under strict anti-abortion laws, doctors in Nicaragua have refused to provide chemotherapy to a woman with cancer because she is 10 weeks pregnant.
Nicaragua's total ban on abortion means that doctors and the women they treat could face jail time if they provide any medical treatment that harms a fetus, even if they are trying to save the mother's life. Because chemotherapy can be harmful to an unborn child, any pregnant woman would be denied treatment under the ban.
Citing constitutional and human rights violations, Amnesty International last week called on Nicaraguan authorities to override the law for the 27-year old Nicaraguan woman.
"It is a travesty of all codes of international justice, ethics and human rights when women are killed, as this woman could be, to serve a narrow view of abortion and 'right to life,'" Dr. Joanna Cain, chief of obstetrics and gynecology at Women & Infants Hospital in Providence, R.I., said.
The Nicaraguan woman, diagnosed with an aggressive cancer that doctors say may have already spread to her lungs, breast and brain, has been unable to receive treatment since she was hospitalized Feb. 2.
"All treatment options, including palliative care to alleviate her pain, may affect the fetus," Esther Major, Central America researcher at Amnesty International, said. "The doctors know she needs treatment but nobody's willing to go forward with [it] until they've had reassurance from the government that they will not be prosecuted."
This case is a powerful example of the impact Nicaragua's anti-abortion laws have had on women's health in the country.By criminalizing all abortion procedures, including therapeutic abortions that aim to protect the life and health of the mother, Nicaragua's ban restricts a woman's access to a range of medical treatments, such as cardiac surgery, radiation and pain-killing medications, Major said.
Before the ban, therapeutic abortion had been practiced in Nicaragua for a century, but criminalization has "led to fear and chaotic thinking by physicians," Cain, of Women & Infants Hospital, said.
Pressure from Nicaraguan Catholic and Christian interest groups played a significant role in passage of the legislation.
The elections of 2006 were close, and both leading candidates, Daniel Ortega and Eduardo Montealegre, sought to garner votes by appealing to the Roman Catholic church, among others. As a result, both candidates endorsed a ban on abortion.
Although 21 Nicaraguan medical associations protested the ban when introduced and made a formal statement warning that if passed, it would hinder health professionals' ability to practice medicine, the warnings were ignored and the total ban went into effect in 2008.
"It's astounding that the government would ignore their own doctors, their own women, on this issue," Amnesty's Major said.
Organizations such as the Nicaraguan Society of Gynecologists and Obstetricians and the Nicaraguan Society of General Medical Practitioners continue to speak out against the ban, but doctors are afraid of personal liability and refuse to offer potentially abortive treatments.
Treating pregnant women is "difficult and dangerous" for doctors, Major said
"Some of them are risking their careers to provide proper care," she said. "They're in an impossible position."
The law doesn't just prevent necessary treatments, doctors say, it prevents meaningful discussion with the patient about their condition and their options.
Cain said doctors must defy the laws. In Nicaragua "where women have no reproductive rights, physicians have an ethical obligation to speak up, to advocate, and even courageously act to save the lives of their patients," she said.
"By failing to act, physicians fail to live out the basic ethical tenets -- [first, do no harm] -- of their profession."
But Dr. Ian Holzman, chief of the Division of Newborn Medicine at Mount Sinai Medical Center in New York City, said the issue was a little more complicated when it came to the conscience of doctors.
"Many of us feel that a physician who doesn't want to do something for moral reasons is obligated only to refer the patient to another provider," he said, but with total ban, this alternative doesn't readily exist in Nicaragua.
Nicaragua's ban violates the right to life stated in Nicaragua's constitution, as well as the right to life promised by the United Nations Human Rights Committee, to which Nicaragua is party, according to Amnesty International. Internationally, health organizations echoed Amnesty's dismay and have expressed opposition to the total ban.
Eleven member states of the United Nations and four expert U.N. committees, including those on Torture, Human Rights and Discrimination Against Women, have urged Nicaragua to amend its laws on abortion because of such violations and the documented rise in maternal deaths since the law took effect.
The World Medical Association put forth an emergency resolution to Nicaragua in October to repeal the legislation, saying that the law "could result in preventable deaths of women".
Nicaraguan groups asked the Inter-American Commission on Human Rights on Feb. 18 to request "special measures" to allow this particular 27-year-old woman to receive treatment.
In response to the requests, the government said it has appointed a commission of doctors to look into the issue, though for this young mother-to-be, a few months delay could mean irrevocable damage from the cancer.
"In some countries, women do not have access to proper medical care because they live too far from a hospital or there aren't enough doctors," Amnesty's Major said. "In this case, the only obstacle is a man-made law. It's a human rights scandal."