Ronald Alvarez, MD
Sophie’s Choice is the title of 1982 critically acclaimed movie set during World War II in which the title character Sophie must choose between the lives of her two children while imprisoned in a Nazi concentration camp. She is given an impossible choice: pick one to live while the other is gassed, or else watch both die immediately if she fails to choose. For Sophie there is no best option; however, not making a choice carries an even heavier consequence. The title has become a metaphor for difficult choices associated with any challenging situation an individual faces.
Such is the circumstance that some pregnant patients with cancer face. For example, what are the treatment choices for a patient diagnosed with locally advanced stage cervical cancer in the first trimester? Cervical cancer is one of the most common cancers found during pregnancy and occurs in approximately 1 in 10,000 pregnancies. The NCCN recommends chemoradiation for such a patient, which is undoubtedly feticidal. Neoadjuvant chemotherapy has been reported but can be associated with adverse fetal effects particularly in the first trimester and has not yet been shown to be equivalent in terms of maternal cancer outcomes.
How are treatment decisions of aforementioned patient affected if she lives in a state where the abortion care is restricted or has been eliminated as a result of the Supreme Court’s 2022 Dobbs decision? Interestingly, 17 of the 19 states that have cervical incidence rates above the U.S average (7.7 women per 100,000, ACS 2023 data) have either eliminated or severely restricted abortion access. Higher cervical cancer incidence rates and limited access to abortion are also known to disproportionally impact women of color and women with fewer resources.
Susan Modesitt, MD
What are the ethical considerations for the patient and her physician in this situation? Under past circumstances in the United States, the patient would have been allowed the autonomy to make the Sophie’s Choice decision to either proceed with immediate chemoradiation that undoubtedly would result in pregnancy loss or to select other treatment strategies that allow pregnancy continuation to a more viable gestational age with the potential risk of compromising her long-term outcome. The physician and the legal system were previously obligated to respect her ability to make such a decision.
How are these ethical considerations impacted if the patient lives in a state with restricted or eliminated abortion access? In Tennessee, abortion care is allowed only “to prevent the death of the pregnant woman or to prevent serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman.” (https://www.capitol.tn.gov/Bills/111/Bill/SB1257.pdf). Thus it is unclear whether the patient still retains her autonomy regarding treatment if it includes abortion. Further, physicians and other clinical personnel face uncertainty with respect to their ability to counsel and deliver all evidenced based care options for this woman with advanced cervical cancer. Concerns about criminal charges (particularly in the setting of affirmative defense stipulations) and the impact on professional and personal circumstances provide a Sophie’s Choice decision for caregivers also.
Sophie’s Choice decisions – challenging for patients, challenging for providers – have now become even more challenging in certain states.