An “ongoing, unregulated medical experiment”

"Who, exactly, is that law meant to protect?”

Feb 23, 2024

El Salvador’s complete abortion ban “has resulted in the death and morbidity of thousands of women and girls and the loss of dignity for many more. The total ban on abortion in El Salvador is nothing less than institutionalized violence against women and a form of torture or other ill-treatment.” [1] In its 2017 working visit to El Salvador, the Inter-American Commission on Human Rights (IACHR) “observed that the abortion ban has ‘direct consequences on maternal morbidity and mortality rates.’” [2] The Salvadoran government admits this truth. In El Salvador’s own report to the United Nations, the Salvadoran government “acknowledged that the total abortion ban is hampering further efforts to reduce maternal mortality and that reaching some of the targets is hindered due to ‘socio-cultural’ and economic factors, lack of access to contraceptives and prevalence of violence against women and girls.” [3]

Torture

Denying abortions kills women with dangerous pregnancies, as shown by the examples in yesterday's newsletter. Pregnant people “are forced to undergo prolonged pain and trauma in the full knowledge that their lives hang in the balance.” [4] One El Salvadoran doctor reported:

“some women trying desperately to stay awake so that they would be immediately aware of the deterioration in their condition and could call for life-saving treatment before it was too late: ‘What could have been very straightforward operation is turned into high-risk surgery.’” [5]

“Sometimes women simply discharge themselves from hospital and return home to await their fate with their loved ones.” [6]

“Certainly, women with high-risk pregnancies suffer the most under El Salvador’s abortion law, but the prohibition also takes a psychological toll on doctors. They feel paralyzed and fearful, caught in a dilemma between helping their patients and breaking the law.” [7] As one doctor put it:

“having a case where you know you have to do something but the law forbids it, and then having to watch a life snuffed out right before your eyes, is frustrating and painful.” [8]

“Yanking the decision-making power out of the hands of pregnant people and their doctors gets mothers and children killed. El Salvador currently values the ‘life’ of a doomed fetus over the life of a child rape survivor. Who, exactly, is that law meant to protect?” [9]

“Maternal deaths are just the ‘tip of the iceberg’, as many more women suffer from morbidity and disability following childbirth, which greatly impacts their overall health and well-being.” [10] Maternal morbidity is “any health condition attributed to and/or complicating pregnancy, and childbirth that has a negative impact on the woman’s well-being and/or functioning.” [11] The most severe consequence of morbidity is later death. [12]

Patients whose fetuses are diagnosed are especially at risk of maternal morbidity, not only from pregnancy complications but also from invasive procedures. “In El Salvador, a woman whose life is threatened by fetal deformities is required to stay in the hospital until she gives birth and cannot get needed medical intervention even when her life is on the line.)” [13] A 2023 study found “high rates of serious complications among Salvadoran patients who were forced to carry severely malformed fetuses to term.” [14] The study found:

“Individuals who were required to carry pregnancies with severe fetal malformations to term (or until preterm labor began naturally) experienced high rates of maternal morbidity. More than half (54.9%) of pregnancies experienced at least 1 serious pregnancy-related health complication, whereas 47.9% underwent a physically-invasive medical procedure to manage complications, including cesarean deliveries, decompression amniocenteses, fetal head decompressions, and, in 1 case, a full hysterectomy… We also found striking variation in how physicians managed pregnancies with fatal fetal malformations, suggesting that different interpretations of the law lead to inequities in individual-level patient care.”

Because of El Salvador’s abortion ban, women who experience obstetric emergencies are also at risk of morbidity. El Faro provides a recent example:

“a woman who was 18-weeks pregnant with twins and arrived at the hospital fully dilated. The expulsion of the first baby caused membranes to rupture, but the second baby remained inside her uterus 24 hours later. The woman knew that her 18-week-old fetus had no chance of surviving outside the womb and wanted her doctor to induce contractions to remove it; she was told that if they did she would be “put in jail.” She had to wait and endure severe pain, while the fetus caused a serious infection in her uterus. Eventually, the fetus’s heart stopped beating and was removed.” [15]

Allowing infection to set in can cause septic shock and death, as well as infertility. Many women have to undergo further surgeries to recontrust their uteruses. We have seen this reality play out in Texas and other abortion ban states.

“The effects of this legislation are nothing other than institutionalized violence and amount to torture and other forms of ill-treatment.” [17] It’s “physical and mental torture meted out by the health care” system. [18]

Since the passage of the abortion ban in 1997, “international treaty monitoring bodies, which monitor state compliance with international human rights treaties, including the Committee against Torture and the Committee on the Rights of the Child, have consistently criticized the ban as a violation of the fundamental rights of women and girls. These bodies have called on El Salvador to decriminalize abortion and ensure its availability in accordance with international human rights obligations, which include cases where there is risk to a woman’s or girl’s life or to her physical and mental health, in cases of rape or incest and in some cases of foetal impairment.” [19] “[T]he Committee against Torture noted that El Salvador’s law, which criminalizes women for undergoing an abortion, has resulted in serious harm to women, including death, and implicates Articles 2 and 16 of the Convention against Torture. Article 2 places an obligation on El Salvador to ‘take effective legislative, administrative, judicial or other measures to prevent acts of torture in any territory under its jurisdiction’ and provides that: ‘An order from a superior officer or a public authority may not be invoked as a justification of torture.’” [20] Yet, El Salvador continues to enforce its ban, which is a source of national pride.

An “ongoing, unregulated medical experiment”

“Conservative treatment”

El Salvadoran doctor Guillermo Ortiz “described the approach he and his colleagues use with treating very ill pregnant women,” which they refer to as “conservative treatment.” [21]

“When we look to international health literature to guide us about how best to treat certain illnesses — for example, metastatic breast cancer and an early pregnancy — the experts suggest terminating pregnancy. We can’t follow that suggestion, though. And, when we seek guidance on how to proceed without terminating the pregnancy, there’s none to be had. And so we forge our own experience… For example, in the case of cancer, we give the lowest dose of chemo, rather than give her the best, most effective treatment, because we have to worry about the fetus.” [22]

“Ortiz’s discomfort with conservative treatment is that it isn’t really treatment at all. In the absence of established medical guidelines, let alone systematic research into how or whether breast cancer chemotherapy works when given at low doses to pregnant women, El Salvador is conducting an ongoing, unregulated medical experiment on this segment of its population — the women and fetuses alike” (emphasis mine). [23]

Ectopic Pregnancy and Expectant Waiting

“The impact of conservative treatment [under El Salvador’s total abortion ban] is perhaps most readily observed in the way Salvadoran doctors treat [tubal] ectopic pregnancy.” [24] Ectopic means "occurring in an abnormal position or in an unusual manner or form.” [25] An ectopic pregnancy occurs when a fertilized egg implants in a place it shouldn’t. A tubal ectopic pregnancy, which is never viable, is when the egg implants in the fallopian tube. Tubal ectopic pregnancy “is the most common cause of maternal mortality in the first trimester... If left untreated, it can cause major internal bleeding and death.” [26] Fallopian tubes are very small and are not able to stretch to accommodate a growing embryo. Thus, failure to terminate a tubal ectopic pregnancy will result in the rupture of the fallopian tube, causing massive bleeding. As such, tubal ectopic pregnancies “always requires treatment.” [27]

“The most common drug used to treat [tubal] ectopic pregnancy is methotrexate. This drug stops cells from growing, which ends the pregnancy. The pregnancy then is absorbed by the body over 4–6 weeks. This does not require the removal of the fallopian tube.” [28] A simple injection of methotrexate is the preferred treatment because this method preserves the patient’s fertility and relieves the patient of incurring the added risks associated with surgery. If it is not caught early enough, doctors will perform a salpingostomy. “A salpingostomy entails an incision into a fallopian tube over the site of ectopic pregnancy and removal of the ectopic pregnancy to spare and retain patency of the fallopian tube for future fertility.” [29]

However, doctors in El Salvador are prohibited from terminating ectopic pregnancies because of the country’s complete ban on abortion. This is because the Catholic Church reigns supreme in El Salvador, and church dogma governs medical care for pregnant patients. The Ethical and Religious Directives for Catholic Health Care Services, a set of policy prescriptions published by the United States Conference of Catholic Bishops (USCCB) which govern healthcare in Catholic hospitals, state, "In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion" (Directive #48). [30] [31]

In the case of a tubal ectopic pregnancy, Catholic ethicists consider a methotrexate injection and a salpingostomy to be direct abortions. Instead, removal of a patient’s fallopian tube is considered the only morally licit treatment. [32] In The Principle of Double Effect: The Roman Catholic dogma animating the anti-abortion movement, I explained the Principle of Double Effect, along with its real-life applications and implications:

"A fundamental flaw is its failure to recognise that the person affected by an action is the one who must evaluate the harm and benefit arising from it.” "Consider ectopic pregnancy. The doctrine permits the removal of the fetus with the fallopian tube. But it is sometimes possible to spare the woman surgery by giving her an intramuscular injection of methotrexate... The doctrine does not allow this. It insists on the surgery.” Is it ethical to unnecessarily rob a patient of her fertility and force her body to endure the risks of invasive surgery? "A principle which makes the mother suffer extra harm without any advantage to the fetus, is unreasonable," and undoubtedly cruel.”

If you have not yet read that piece, I suggest you do so, in order to fully understand the ways in which Catholic dogma puts patients’ lives at risk and unnecessarily inflicts harm upon them.

In El Salvador, “conservative treatment” means that “doctors treating these patients — some as young as nine — are forced to stand by and wait until the tube ruptures,” putting patients’ lives on the line. [33] Once the fallopian tube ruptures, doctors must act quickly to save the patient’s life by amputating the fallopian tube (salpingectomy). “In the case of an ectopic pregnancy, waiting can be very dangerous.” [34] “[D]elaying treatment increases the risk of a tubal rupture, which invariably damages the woman's reproductive ability, causes a serious infection in her abdomen, and endangers her life.” [35] “There is no medical reason to wait: these fetuses will not survive. The law forces women to risk their lives for a pregnancy that will never become a child.” [36]

One Salvadoran doctor described, “with evident frustration,” the conservative treatment of ectopic pregnancies under the abortion ban in El Salvador. [37] First, the patient is hospitalized. Then, according to the doctor:

“you watch her night and day with scans, and the minute it bursts, you operate and take the tube… She’s in imminent risk of dying and I’ve got the responsibility of saving her life. Waiting is totally contrary to medical principles. It’s no different from having an aneurism in the brain; once can see from scans that it’s growing and growing. Why would you wait until it explodes? There’s no single medical principle that would justify waiting.” [38]

Another doctor, working at a public maternity ward in El Salvador, lamented:

“Even though we know that we must intervene, we can’t because the embryo is still alive. So, we have to wait until the patient shows signs of haemorrhage, because otherwise it’s illegal. Some colleagues will note on ultrasound scans: ‘ectopic pregnancy: embryo alive’. Beneath that will be noted: ‘remember, it is illegal to do this’. And the patient is even more confused.” [38]

In a 2023 article at El Faro, an internationally acclaimed Salvadoran media outlet, Natasha Reifenberg and Jocelyn Viterna wrote, “To be clear, Salvadoran law has created a practice incompatible with ethical medicine. It demands that doctors let a pregnant woman die so that an embryo or fetus, which will inevitably die, expires inside the mother’s body, not outside it.” [39]

Bringing the El Salvador experiment to America

The anti-abortion movement in the United States is increasingly attempting to bring El Salvador’s “ongoing, unregulated medical experiment” to US maternal healthcare, including El Salvador’s dangerous, conservative treatment of tubal ectopic pregnancies. “[S]ome abortion opponents have started making the argument that terminating an ectopic pregnancy by medication or surgery is not medically necessary. At the Federalist, Boorman argues that instead of abortion, patients with ectopic pregnancy should be closely monitored by their doctors (a process called “expectant management” or “watchful waiting”). Sometimes, she writes, the patient will miscarry with no need for intervention. If the tube ruptures, the patient can be treated with a blood transfusion procedure — though, she acknowledges, there is a… risk of death. She also argues that sometimes, an ectopic pregnancy can move on its own, reimplanting in a safer location and even resulting in a healthy birth. Doctors, however, say it is not possible to carry an ectopic pregnancy to term and have a child.” [40] “Once a diagnosis of ectopic is made, that pregnancy cannot continue,” explains Dr. Daniel Grossman, a professor of obstetrics, gynecology, and reproductive services at the University of California, San Francisco. [41]

Yesterday, Abolitionists Rising - a group who wishes to completely abolish abortion in the US and prosecute abortion patients for homicide - published an error-riddled position piece (the author doesn’t seem to know that the cervix is part of the uterus, for example). The group’s position piece states that, when cardiac tones can be detected in a tubal ectopic embryo, neither a methotrexate injection, salpingostomy, or salpingectomy are morally permissible, because treating ectopic pregnancies will “cause the death of the baby.” [42] That’s right, folks.— Abortion “abolitionists” intend to deny pregnant patients treatment for life-threatening tubal ectopic pregnancies even though these embryos will never survive.

Instead of providing pregnant patients necessary, life-saving healthcare, abolitionists insist on forcing women, girls, and embryos into an “ongoing, unregulated medical experiment.”

According to the position paper, the only “ethical” treatment for tubal ectopic pregnancies is “watchful waiting/expectant management and an attempted transplant of the baby to the uterus if the mother’s condition worsens.” [43] Yes, you read that correctly.— Abortion “abolitionists” want to force pregnant patients to undergo invasive and dangerous medical experimentation against their will. In other words, the “abolitionists” intend to enact a future of forcible experimentation upon girls and women, treating their bodies as mere lab rats and guinea pigs. Because girls and women aren't actually persons.

Of importance, “an ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment.” [44]

The human rights of all born persons “include the right to life, the right to be free from torture and other ill-treatment, the right to privacy, the right to health, the right to determine the number and spacing of children, the right to due process and the right to freedom from discrimination.” [45] Unfortunately, these rights don’t exist for pregnant patients in “pro-life paradise.”

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