Two-Minus-One: The Paradox of Limitless Choice and Reduced Pregnancies

Reproductive medicine has created a huge paradox: by creating life where none seemed possible, doctors frequently generate more fetuses than intended or expected. In the mid-1980s, doctors provided an escape route to deal with these super-pregnancies, terminating all but two or three fetuses to lower the risks to the mother and the babies that would be carried to term. But what started as an intervention in cases of extreme circumstances has silently become an option for women who are carrying twins; pregnancy reduction has become less of a medical decision than an ethical dilemma. As science offers us the chance to intervene more at the beginning and end of life, we are being called upon to negotiate a new ethical balance. Just how far are we willing to go to create life as we want it?

The issue of terminating half of a twin pregnancy has proved more controversial than reducing triplets to twins or aborting a single fetus. Why? After all, the maths is the same in every one of these situation. It is always minus one. Perhaps it has something to do with the fact that twin reduction (unlike abortion) involves selecting one fetus over the other when either one is equally desired. Perhaps it is rooted in our culture’s idealised philosophy of singularity and the notion of twins as soul mates.

While there is no agency to track the number of reductions occurring, recent reports in the United States have shown that the demand for reduction to a single fetus, while still rather uncommon, is on the rise. New York’s Mount Sinai Medical Centre – one of the principal providers of the procedure – reported that 15% of reductions were to a singleton by 1997. In comparison, 61 out of 101 were to a singleton last year (and 38 of those pregnancies started as twins). This increase has instigated unease among medical practitioners; many doctors who perform reductions are refusing to go below twins. It is not only doctors who are uncomfortable; many abortion rights activists have vocalised their anxiety over the issue.

 The first doctor to reduce a pregnancy was Mark Evans, an obstetrician and geneticist. From the outset, Evans maintained that the industry needed guidelines to perform this procedure and in 1988 he collaborated with an ethicist from the National Institutes of Health to issue them, one of which included the tenet that most reductions below twins would be a violation of ethical principles. Two years later, as the demand for twin reductions increased, Evans published another article, arguing that reduction to singletons “crosses the line between doing a procedure for a medical indication versus one for a social indication.” He advised his colleagues not to become “technicians to our patients’ desires.”

The rationalisation for reduction has always been rooted in the desire to increase a woman’s chance of bringing home a healthy baby; medical risks escalate with every fetus she carries. The procedure (usually performed around the week twelve of pregnancy) involves a fatal injection of potassium chloride into the fetal chest. Over time, the dead fetus withers, but it remains in the womb until delivery. Doctors found performing the reductions to be unnerving, especially since the procedure is monitored by ultrasound, providing clear visuals, which is not the case for abortion procedures. Even doctors in opposition to abortion were of the mind that it was better to save some fetuses than to risk them all.

Throughout the early 1990s, the medical consensus was that reducing pregnancies of quadruplets or quintuplets undoubtedly improved the health of the woman and her fetuses. Anything less than twins, though, was usually unacceptable. However, in 2004 Evans reversed his stance, and endorsed twin reductions in a major obstetrics journal. Analysing changing demographics, he argued that there were several scenarios in which it became a very real possibility. Take, for example, the fact that more women were putting off pregnancies to their 40s and 50s (often thanks to donor eggs). Evans was able to understand that these women would not always want to be worrying about two teenagers in their 60s. He also took account of women who were in second marriages, who might already have children from a previous marriage but wanted to create a child with their new spouse. Whatever their reason, Evans turned his attention to patients who felt they lacked the resources to deal with raising twins. In addition to the change in demographics, Evans highlighted that the element of risk had decreased massively.

Studies had started to reveal that the risks of twin pregnancies were greater than previously thought, carrying an increased chance of prematurity, low birth weight, and cerebral palsy in the babies and gestational diabetes and pre-eclampsia in the mother. Taking into account what he referred to as a “juncture in the cultural evolution of human understanding of twins,” Evans came to the following conclusion:

 “Parents who choose to reduce twins to a singleton may have a higher likelihood of taking home a baby than pregnancies remaining with twins.”

Essentially, his argument boils down to this: “Ethics evolve with technology”.

Not all medical practitioners are in accord. Dr. Richard Berkowitz, a perinatologist at Columbia University Medical Centre, an early practitioner of pregnancy reduction, says:

“The overwhelming majority of women carrying twins are going to be able to deliver two healthy babies.”

Yet, while Berkowitz insists that there is no clear medical benefit to reducing below twins, he will perform the procedure at the request of a patient:

“In a society where women can terminate a single pregnancy for any reason — financial, social, emotional — if we have a way to reduce a twin pregnancy with very little risk, isn’t it legitimate to offer that service to women with twins who want to reduce to a singleton?”

Other doctors, refuse to reduce below twins unless the pregnancy poses extreme medical problems. Evans himself predicted that this would be the case.

Choice and ethics are in conflict. Sheena Iyengar, author of The Art of Choosing, suggests that ‘limitless choice’ is a particularly American ideal. In a talk she gave at a TED conference last year in Oxford, she said:

“The story upon which the American dream depends is the story of limitless choice. This narrative promises so much: freedom, happiness, success. It lays the world at your feet and says you can have anything, everything.”

This revolution of choice, however, has unsettled the ethical boundaries and a lot of work needs to be done to define them, not only in the area of pregnancy reduction but also abortion, egg donation, sex selection, and surrogacy, among others. The ability of women to control their fertility has created a myriad of choices but they are not straightforward. In fact, the choices are usually going to be incredibly difficult, especially in the case of twin reduction when both fetuses appear healthy.

Bettina Paige, writing for Elle related her own experience of selective reduction in 2010 in an article entitled ‘The Choice’. Paige already had one son, but wanted another child. When she became pregnant with twins (one boy and one girl), she and her husband made the decision to have a selective reduction and chose only to carry the girl to term. She said that to have twins would have caused financial difficulties and predicted that having twins would put the “fragile equilibrium” of her marriage and family at risk. She wrote:

“My husband was convinced that twins would radically change our lives for the worse. We’d have to leave our beloved neighbourhood for a place with cheaper rents and better public schools — there was no way we could afford private education for three kids. We’d kiss goodbye any hope of career advancement, at least for the foreseeable future. To his list, I added the loss of my income, necessary to meet our expenses. I couldn’t see how I’d be able to resume working after the birth since we could never afford full-time help, and — no matter how well they napped — two infants wouldn’t leave much time for anything else.”

From reading her article, one can do nothing but acknowledge how difficult her choice was. She asked herself:

“Wasn’t sacrifice part of what being a parent was all about? Was it more accurate to say that we didn’t want to handle twins, rather than we couldn’t?”

Even from a pro-choice perspective, her dilemma is a tricky one. For some, however, it is not a grey area at all. Comedian Sara Benincasa tweeted her reaction after reading the article:

“Oh, I’m well-off and I paid for IVF, but eww, my husband hates kids, so the boy has got to go. Convenient blame…I’d like to retroactively abort this woman and her husband.”

The allusion to retroactive abortion is disturbing. Yes, Paige’s husband is not well represented in the article – after all, she reports that he says: “I told you when you started all this that I didn’t want twins.” – but she does not use him as her excuse for having the procedure. Ultimately, Paige made a conscious choice:

“I know it sounds selfish, but I wanted to protect the well-being of the people already in my life — my son, my husband, and, yes, myself.”

Not all of us would have made this decision, but real reproductive freedom means freedom to make the choices that not everyone will approve of. If only ‘unselfish’ reasons apply in whether or not one chooses not to have a child, how do we monitor it? What are valid reasons? Singleness? Education? The simple case of just not wanting a child at a certain point of your life? Paige’s decision may seem less ‘justified’ than others, but at the end of the day, it is not our place to decide what is ‘right’ or ‘wrong’ for another person. Protecting your own right to choose means defending Paige’s, even if you do not accept it.

Yesterday, William Saletan published a topical article in Slate, asking “Why do ‘reductions’ of twin pregnancies trouble pro-choicers?” In his introduction he gets straight to the heart of the matter:

“What’s worse than an abortion? Half an abortion. It sounds like a bad joke. But it’s real.”

Responding to an article on the issue of pregnancy reduction in the New York Times Magazine, Saletan acknowledges that there has been an air of discomfort among pro-choice blogs, Slate included. RH Reality Check, a website dedicated to abortion rights, ran an item raising concern over one woman’s reduction decision. Jezebel, infamously known to be pro-choice, has also acknowledged the ‘complicated ethics’ of reduction. Comments following from these articles are full of similar reservations from pro-choice readers. Their reaction seems strange since a reduction is, essentially, an abortion. Saletan says:

“If anything, reduction should be less problematic than ordinary abortion, since one life is deliberately being spared. Why, then, does reduction unsettle so many pro-choicers? For some, the issue seems to be a consumer mentality in assisted reproduction. For others, it’s the deliberateness of getting pregnant, especially by IVF, without being prepared to accept the consequences. But the main problem with reduction is that it breaches a wall at the centre of pro-choice psychology. It exposes the equality between the offspring we raise and the offspring we abort.”

The binaristic mindset formed by the terminological distinction between ‘a fetus’ and ‘the child’ seems to be the problem; a linguistic transformation seems to occur in the moment when the fetus is assuredly not fated for abortion. It is this distinction that seems to saturate pro-choice thought. A wanted fetus is a baby; a fetus you don’t want is a pregnancy. Saletan continues:

“Under federal law, anyone who injures or kills a ‘child in utero’ during a violent crime gets the same punishment as if he had injured or killed ‘the unborn child’s mother’, but no such penalty applies to an abortion for which the consent of the pregnant woman… has been obtained.”

The uncertainty is bound up in the fact that pregnancy reduction destroys this distinction. In a single pregnancy there is both a wanted and unwanted fetus, which becomes especially complicated in the case of identical twins.

Saletan goes on to present Sophie’s Choice as a common theme in abortion decisions:

“To give your existing kids the attention and resources they’ll need, you have to terminate your fetus. This rationale fits the pro-choice calculus that born children are worth more than unborn ones. But in the case of reduction, the child for whom you’re reserving attention and resources is equally unborn. She is, and will always be, a living reminder of what you exterminated.”

This is the bottom line which troubles pro-choices. As one Jezebel reader says:

“I’d have a much easier time aborting a single baby or both twins than doing a reduction. When you reduce, the remaining twin will remain a persistent reminder of the unborn child. I think that, more than anything would make killing that fetus feel like killing another human, even though it wasn’t fully developed. It would feel that way because you would have a living copy of the person you killed.”

When it comes to twin reduction, in particular, the dilemma is as follows: how can you watch one child grow up without it becoming a living reminder of the child that never was? How can you come to terms with the fact that the only thing that separated them was your will to choose? It is clearly a complicated issue and the uncertainty of ethics does not make the matter an easier one to conceptualise and solve. What it highlights, however, is that while personal control of family planning is a right, it is not always a privilege. So, whatever we think about the individual choices a woman makes, we should remember that the existence of medical procedures that make their choices possible do not make them easier. Josephine Johnston, a bioethicist at the Hastings Centre in Garrison, New York, sums it up as follows:

“The dark lining of that otherwise very silver cloud is that you make the choice of when to get pregnant, and so you feel really responsible for its consequences, like do you have enough money to do it well, and are you going to be able to provide your child with everything you think you ought to provide? In an environment where you can have so many choices, you own the outcome in a way that you wouldn’t have, had the choices not existed. If reduction didn’t exist, women wouldn’t worry that by not reducing, they’re at fault for making life more difficult for their existing kids. In an odd way, having more choices actually places a much greater burden on women, because we become the creators of our circumstance, whereas, before, we were the recipients of them. I’m not saying we should have less choices; I’m saying choices are not always as liberating and empowering as we hope they will be.”

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Categories: Beliefs, Morals, Health, Medicine, People, Science, Technology

Author:Mary-Ellen L

Lives at Lecturer in Literature and Philosophy, Poet and Professional Cynic.

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