When pharmacies ran out of the free pain medication he was entitled to under Russia's public health system, dying cancer patient Viktor Sechin turned to Aleftina Khorinyak, a doctor and longtime friend, for help.
For about a month in early 2009, Khorinyak prescribed him a nonsubsidized version of the opioid painkiller Tramadol to help ease the suffering caused by his terminal cancer.
"They didn't give him any Tramadol for 52 days. I could no longer bear watching him suffer," Khorinyak recalls. "He moaned and thrashed about on his bed, he was in such excruciating pain."
Sechin, who was also severely disabled, succumbed to cancer two years later at his home in the Siberian city of Krasnoyarsk, aged 57.
What Khorinyak intended as gesture of compassion, however, has landed her in court on charges of drug trafficking and document forgery. Both are criminal offenses that carry a total of up to eight years in jail.
Her trial has drawn strong condemnation from rights advocates, who accuse Russian authorities of hounding the 71-year-old doctor on a mere technicality -- prescribing nonsubsidized Tramadol while Sechin was formally only allowed to receive the medication free of charge under a state program to benefit economically disadvantaged people.
Overly Strict, Bureaucratic Policies
It has also shone a rare spotlight on the plight of terminally ill patients in Russia, many of whom continue to die in agony amid chronic drug shortages and a general lack of awareness about how to treat pain.
Rights advocates and health experts pin much of the blame on the stringent regulations that govern the use of controlled substances in Russia. While the country has an obligation under international law to regulate access to opioid medications, its drug-control regulations are criticized for routinely denying patients adequate pain relief.
Rights groups see Khorinyak as a victim of these overly strict and bureaucratic policies. "This woman essentially fell through the cracks of the system of drug regulation in Russia," says Tanya Cooper, a researcher at Human Rights Watch.
"The regulations are inflexible. In this case, they don't allow the patient to receive medication," Cooper adds. "This case shows that the drug regulations that currently exist in Russia allow people with terminal cancer to be left in pain for many days."
The distribution of opiates is so restricted in Russia that patients are barred from holding stocks of medication, forcing them to continuously seek new prescriptions and queue up for their drugs. There are now fears that the criminal charges against Khorinyak will further deter Russian doctors from prescribing morphine and other potent painkillers.
'A Fundamental Aspect Of Patient Care'
A number of health advocates believe the denial of pain relief for terminal patients amounts to torture and is a serious human rights violation. They stress that Russia is a signatory of the International Covenant on Economic, Social, and Cultural Rights, which guarantees the right to "the enjoyment of the highest attainable standard of physical and mental health."
"Palliative care is not a charitable activity or a footnote of medicine," says Diana Nevzorova, head doctor at Moscow's oldest hospice for the terminally ill, founded in 1994. "It is a fundamental aspect of patient care because, unfortunately, everyone dies."
Russia is home to roughly 100 hospices offering end-of-life care for patients and their families -- a significantly lower per-capita ratio than in Western countries. Britain, for instance, has more than 260 hospices and palliative inpatient units for a population less than half that of Russia.
Nevzorova says Russia's palliative-care system is still "in its infancy," with the majority of hospices run by charitable organizations and medical staff woefully untrained in modern methods of pain management.
'How Can We Talk Of Progress?'
Awareness of the right to a dignified, pain-free death is nonetheless slowly taking root in Russia.
The ordeal of popular bard Ada Yakusheva, who was denied pain medication until one day before dying of cancer in October 2012 due to bureaucratic hurdles, sparked public dismay.
Russia's Health Ministry, too, appears to be waking up to the need for better palliative care. Health officials issued a set of directives last year to improve end-of-life treatment, ordering the creation of hospices and palliative-care units across the country.
Nevzorova, however, says the new rules have been met with disappointment by experts. "The palliative care described in the government's decree addresses mostly palliative medical care," she says. "It says nothing about the philosophy of hospice care, about nursing, about social and psychological support."
The charges against Khorinyak illustrate the uphill battle waged by Nevzorova and other doctors advocating a more compassionate approach to pain.
Khorinyak was found guilty of drug trafficking and forgery of documents in May along with another female friend of Sechin who purchased the nonsubsidized medication for him. The verdict, however, was invalidated over a technical detail. A new trial began in November.
Nevzorova, while deeply sympathizing with the two women, says the case is drawing much-needed attention to Russia's shortcomings in caring for its terminally ill citizens.
"People have an undeniable right to live and die with dignity. A country's level of palliative care reflects its level of social development," she explains. "If we don't start taking proper care of our dying patients, what kind of progress can we talk about for our country?"