Procreative Beneficence or Unethical Termination? Physician Efforts Fail to Diminish the Controversial Nature of Selective Reduction

Medical ethicists, physicians, reproductive professionals, scientists, and other interested stakeholders acknowledge the controversial nature of selective reduction, a medical procedure sometimes performed several weeks after in vitro fertilization (IVF). Is selective reduction morally right? Is it legal? Must it happen? Is selective reduction optimal for the mother and unborn child(ren)? Whose rights and/or autonomy are at stake? Sometimes referred to as multifetal pregnancy reduction (MPFR), selective reduction terminates one or more developing fetuses to ensure a higher likelihood of the health, survivability, welfare, and/or quality of life of the mother and/or unborn child(ren).[1] [2] [3] However, some say that selective reduction is akin to abortion – simply nothing short of murder – or “targeted raids on children using chemical weapons in order to kill them,” and should be shunned in all circumstances.[4] The decision to perform selective reduction is carefully considered by the mother and health care provider with an ultimate goal of the best outcome for the mother and unborn child(ren).[5]

Despite physician efforts to minimize the need for selective reduction, principles of utilitarianism, rights/autonomy, and justice demonstrate that selective reduction is sometimes necessary to ensure the health, safety, welfare, and quality of life of both mother and child(ren).[6] [7] [8] The conflict is that the morality of selective reduction can be questionable.[9] Likewise, minimal legal guidance prohibiting the procedure is available. It follows that the law fails to characterize selective reduction as murder.[10]

Image: Pregnancy. Credit: Wellcome Collection and Bill McConkey. CC BY

Moral considerations include reasons for selective reduction (e.g. health of the mother and/or fetus? convenience? socioeconomic? cost considerations? strain on current family structure? religion? politics (pro-choice or pro-life)?), how one selects which fetus will live and which one will die (e.g. sex? health? ease of access for the physician to safely insert a needle? randomness?), the number of embryos implanted (a smaller number means a lesser likelihood that selective reduction need occur at all), and timing of the selective reduction with regard to when life begins (e.g. at conception? At embryo implantation? At the time a fetal heartbeat can be detected? At the time the fetus can feel sensation?).[11] [12] Peter Singer dismisses as arbitrary the idea that life is measured from the moment of conception to birth and afterward. Instead, he proposes that living humans possess rationality, self-consciousness, and awareness. All of these are absent from the developing fetus. However, others disagree. Selective reduction critics view the existence of life as anywhere on the spectrum from conception to birth.[13] [14] Thus, one cannot find a definitive right or wrong answer to the selective reduction is “bad” morality proposal.

Dorkina Myrick, MD, PhD, MPP, is a physician-scientist and pathologist trained at the National Institutes of Health. Dr. Myrick also previously served as a Senior Health Policy Advisor on the United States Senate. She obtained her Master of Public Policy degree at the University of Oxford in Oxford, England. Dr. Myrick is currently a JD candidate at the Boston University School of Law.

References:

[1] “Patient Information Series.” Patient Education Committee and Publications Committee. American Society for Reproductive Medicine. December 2014

[2] Antsaklis A, Souka AP, Daskalakis G, Papantoniou N, Koutra P, Kavalakis Y, Mesogitis S. “Pregnancy outcome after multi-fetal pregnancy reduction.” J Matern Fetal Neonatal Med. 2004 Jul;16(1):27-31.

[3] In vitro fertilization. Mayo Clinic. http://www.mayoclinic.org/tests-procedures/in-vitro-fertilization/basics/risks/prc-20018905. June 27, 2013

[4] Fournier, Deacon Keith. “Selective Reduction? Killing a Twin in the Womb and the Culture of Death.” Catholic Online: http://www.catholic.org/news/national/story.php?id=42434. August 18, 2011.

[5] “Multifetal Pregnancy Reduction.” American College of Obstetricians and Gynecologists. Committee opinion Number 553. February 2013. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Multifetal-Pregnancy-Reduction

[6] Zaner et al. Selective termination in multiple pregnancies: ethical considerations. Fertility and Sterility. Volume 54, Issue 2, August 1990, Pages 203-205.

[7] Evans, Mark et al. Selective First-Trimester Termination in Octuplet and Quadruplet Pregnancies: Clinical and Ethical Issues. Volume 71. Issue 3. Part 1. March 1988. Online: https://journals.lww.com/greenjournal/Abstract/1988/03000/Selective_First_Trimester_Termination_in_Octuplet.1.aspx.

[8] Pennings, G. Selective Termination, Fetal Reduction, and Analogical Reasoning. Reproductive Biomedicine Online. Volume 26, Issue 6, June 2013, Pages 525-527. Online: https://www.sciencedirect.com/science/article/pii/S1472648313001223.

[9] Id.

[10] Cheong MA, Tay SK. Application of legal principles and medical ethics: multifetal pregnancy and fetal reduction. Singapore Med J. 2014;55(6):298-301. Online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4294055/.

[11] Claire-Marie Legendre, Grégoire Moutel, Régen Drouin, Romain Favre, Chantal Bouffard. “Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: a narrative review.” Reproductive Medicine. Print: Volume 26, Issue 6, Pages 542–554. June 2013. Online: http://www.rbmojournal.com/article/S1472-6483(13)00068-0/pdf.

[12] “Multifetal Pregnancy Reduction.” American College of Obstetricians and Gynecologists. Committee opinion Number 553. February 2013. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Multifetal-Pregnancy-Reduction

[13] Singer, Peter. Practical Ethics. Cambridge University Press. 1993.

[14] Crome, Keith. “ Is Peter Singer’s Utilitarian Argument about Abortion Tenable?” On Singer’s Utilitarian Argument About Abortion. Richmond Journal of Philosophy 17 (Spring 2008). http://www.richmond-philosophy.net/rjp/back_issues/rjp17_crome.pdf.