Thursday, August 25, 2011

Twins to Singleton: New Ethical Dilemmas

Yesterday I read a fascinating--and somewhat disturbing--New York Times Magazine article about twin-to-singleton pregnancy reductions. Formerly only used to reduce triplets, quadruplets, and above, pregnancy reductions are increasingly sought to reduce twins to a single fetus. A few excerpts from The Two-Minus-One Pregnancy:
For all its successes, reproductive medicine has produced a paradox: in creating life where none seemed possible, doctors often generate more fetuses than they intend. In the mid-1980s, they devised an escape hatch to deal with these megapregnancies, terminating all but two or three fetuses to lower the risks to women and the babies they took home. But what began as an intervention for extreme medical circumstances has quietly become an option for women carrying twins. With that, pregnancy reduction shifted from a medical decision to an ethical dilemma. As science allows us to intervene more than ever at the beginning and the end of life, it outruns our ability to reach a new moral equilibrium. We still have to work out just how far we’re willing to go to construct the lives we want....

The ability of women to control their fertility has created all kinds of welcome choices. “But 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?” says Josephine Johnston, a bioethicist at the Hastings Center in Garrison, N.Y., who focuses on assisted reproduction. “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.” (emphasis mine)
Read the rest here. It's definitely worth your time.
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29 comments:

  1. such an important topic!!!

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  2. Selective reduction is something that has sickened and saddened me ever since I heard about it years ago. A despicable practice.

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  3. As a mom of twins, I can attest to how physically demanding the pregnancy is on the body...but, I also cannot imagine terminating either one.

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  4. As another mom of twins, while it isn't a choice I would make, it's not one I would have easily dismissed either had I found out I was carrying higher order multiples. I look at the risks my twins were exposed to simply for sharing a womb & being born 6 weeks premature (which is considered really good for twins who share a placenta) & imagine multiplying that by 3, 4 or 5. I don't think it's a despicable practice at all - it's a very difficult choice that most families hate finding themselves facing & I do not envy them the process of weighing the risks & benefits of the options facing them.

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  5. I read that article. It took me about 3 days to get through it because it was so hard for me to read.

    What it comes down to, for me, is that while I am very uncomfortable with the idea of reducing a perfectly normal twin pregnancy down to one, I am more uncomfortable with the responsibility for a woman's health being held by anyone but that woman and her chosen health care provider(s).

    Pregnancy is such a difficult, singular moral situation. Yes, there is a baby, who would most likely grow to adulthood. But the woman's body is also HER BODY. This is why there are no easy answers, it is not fully one or the other. It is fully both.

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  6. "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."

    My husband and I were just discussing vaccinations last night, and I had a similar feeling regarding that topic. As my husband pointed out to me, in that case, choice is definitely preferable to the alternative (where people didn't have choices and just hoped nobody died of anything), but sometimes all these choices are quite burdening in a way.

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  7. Very sad topic, but certainly thought-provoking, especially the passage you highlighted.

    A dear friend of mine conceived on child through IVF, and is now trying for another. Her fertility doctor HIGHLY pressured them to implant up to 7 embryos, but they would only agree to two, because they didn't want to be forced to choose to reduce or have her carry seven babies, should all of them "take." They had two implanted the first time, and neither lived to become a viable pregnancy. The second time, they also implanted two (which resulted in a singleton birth), and will have two again this time.

    For many struggling with infertility, and struggling to pay the bills for IVF and other fertility treatments, I can see where the dilemma lies, because it's a whole lot less money to have six embryos planted at once, than to go through IVF three separate times with two implantations each time.

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  8. We just can´t play to be God. We´re not made to choose to kill or let live our babies... therés a post anortion syndrome anybody is talking about. It´s real and the thing is that the feelings emerge by causing important distress and other "minor" diseases. We HAVE to begin to take care of our emotional health if we want to evolve and stop bullying, cruelty, violence in any shape.
    We have to believe life is the most important thing as human race, we have to make the best of our innate creativity to go beyond money issues.

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  9. So it comes down to this in my mind: All the concerns mentioned in what I have read so far is the difficulties after the baby is born - money, time, equal parental affection, etc... So then put one up for adoption and let it live. But that is not mentioned (I'm not done reading its so sad) So What I see so far is nine months of discomfort and risk in carrying a twin pregnancy is not worth the life of the embryo. And killing it is easier than giving it up for adoption so that is the choice made? unconscionable - this is where my defense of women's choice come to a screeching halt. They did have a choice - not to implant babies they didn't want. She says "if the twins had occurred naturally she would have kept them" but not because she had the created in a tube??? How could you ever look at the one who lives and not wonder about the one who didn't.

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  10. I am sickened and saddened by this article. And as for the woman who eliminated 2 of the triplets she was carrying, and plans to tell her daughter, now 2 years old, about it -- how is that girl going to handle the knowledge that it's only pure luck that that needle didn't pick her?

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  11. I'm a mom of 2 sets of twins (both sets spontaneous, monozygotic) so this article was tough to read.

    While I'm not in favor of selective reduction, I can understand that a mother who used IVF and conceived multiples may be more concerned about pregnancy outcomes. I've seen studies that show that moms who conceive twins using IVF were more likely to suffer from preterm birth, cesarean section, and longer NICU stays than twins conceived spontaneously. (http://www.sciencedirect.com/science/article/pii/S000293780300485X) The thought of losing both babies may be enough to push some moms toward selective reduction. I'm sure that any prenatal counseling they receive from their fertility doctors would likely focus more on the pregnancy risks than the logistics of raising twins 9 months later.

    That said, I think sometimes we end up with a blessing that we never would have chosen. At least, that's my take on it.

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  12. I think we are used to thinking that women have abortions because they "can't be mothers right now". But 60% of women who get abortions are already mothers. They just do not feel they can be a mother to another child at that time. Looked at in that light, elective reduction is a very similar choice. These are not unwanted pregnancies; they are just too many children at one time. I understand some people are simply opposed to all abortion and so for them, two-to-one reduction is unlikely to be palatable (not sure how you all feel about higher-order multiples). But I personally can't argue with a woman's own ability to examine her own, very intensely personal circumstances, and make the right choice for her family.

    This doesn't mean that the article did not make me really examine my own beliefs and ethics. It is a challenging idea to wrap our heads around and I can only hope I would never be placed in the same situation and faced with the same decision, because it seemed like a difficult struggle for most of the mothers concerned. I respect the right of the providers who did not feel comfortable with the procedures to decline and help those women find a care provider who is willing to work with her.

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  13. I suspect this is typical of NYTimes coverage of women's issues, where they emphasize the most trivial aspects of an issue out of mundane misogyny.

    I know of one woman who had severe pre-eclampsia with IVF twins, lost both of them and nearly herself, and then went on to have a healthy singleton with FET. I suspect that the majority of twin to singleton reductions are due to health issues, but the NYTimes highlighted the "convenience" side of it.

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  14. Assuming that the mothers were more worried about caring for twins (or triplets or more) than they were worried about pregnancy outcomes, or as Rebecca said about a mother who is aborting a second or subsequent baby, why not decide after birth which baby to keep, and put the other one(s) up for adoption? If the baby is truly unwanted, or would cause too much strain, then it should be relatively easy to let the baby be raised by someone else who will love and want the baby, and for whom the baby will be a joy and not a burden.

    Adoption and abortion are similar in this way -- in both instances, the biological mother does not raise the baby. If the reasoning of the "pro-choice" side is correct, that women ought to be able to choose abortion because they "can't be mothers right now", why isn't adoption even more widely hailed as the remedy? Why is sucking a baby out and disposing of him or her as medical waste the preferred choice to letting him or her be born and live a long and happy life with some other family?

    -Kathy

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  15. Came across that article on another forum I frequent. It is so sad and heart-breaking and I could only read the first page. The thing to remember is babies are already being taken and have been for a long time, due to IF treatments but when it comes up as twins to one baby it sounds so much more REAL than from 6 to 3 or what have you. It sounds like... of course no one would have 6 babies... but twins... how could anyone do that. The point is they absolutely need to limit the number of transfers even though it seems like it makes sense financially like another poster said. I would challenge that it's not financially sound if you end up carrying all 5+ babies along and they all end up in the NICU each with their own nice set of bills!

    But back to the article, as someone who is TTC again I would gladly take those twins off anyone's hands who is thinking of making that horrible, detestable choice.

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  16. so I thought more about this even though trying to get it out of my mind and it almost reminds me of crazed women who kill other women to steal the baby right from their womb. Because they are literally killing to have a baby. someone else's body (albeit very small) is worth sacrificing so they can get the ONE baby they want.

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  17. It's a very tough subject, but I believe I can understand why these decisions are made. Though, it's difficult to not judge at least some of their stories like Jenny from the article. She already had living children and then goes through fertility treatments in her mid-40s? I really don't get that. But, it's not my life and not my decision.

    The first time my husband and I were trying to get pregnant he told me it would be awesome to have twins, but the thought terrified me. I'm happy this procedure is available to the women who need it.

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  18. I love what heather@it'stwinsanity said: "I think sometimes we end up with a blessing that we never would have chosen." That has TOTALLY been my story, and I think along those lines whenever someone is struggling with being pregnant. No twins, but I have five, and #2 and #3 were unplanned by my husband and me. I THOUGHT GOD WAS TRYING TO KILL ME. Especially with #3, I was incredibly ill even before I got pg, and I could totally see how/why some mothers would choose abortion, feeling overwhelmed by just being pregnant, and the thought of taking care of yet another child... However, that son that I thought would literally be my end turned out to be my salvation, because at 13 months, he was diagnosed with celiac disease, which then led to my own dx. That son, whom I would not have chosen for myself -- literally -- saved my life. I was so ill both physically and mentally. I am now sound of mind and body. Perhaps the diagnosis would have come a different way, even if I had not conceived and carried and birthed that son... but I absolutely know that God used that event in my life to seal it in my heart that while we may not choose a particular child, He has chosen that child for us, to be a blessing, and to be exactly what we need, at exactly the right time.

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  19. Wow, a lot of judgment and hate on women who are making this decision, and I find the solution of adoption for one of the babies to be boggling. I can't imagine any less judgment being leveled at a woman who gives birth to two babies, and randomly picks one to relinquish for adoption...and in that case everyone in her life would know she was doing it, unlike the privacy of the decision to reduce.

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  20. right why put it up for adoption when you can just kill it - totally mind boggling.

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  21. I'm not sure why this is any worse than regular abortion. It doesn't bother me, frankly. I can't imagine doing it myself, but I wouldn't force any woman to live with an unwanted pregnancy, so why would I force a women through an unwanted dual pregnancy?

    Like Ashley, I find it hard to believe reducing twins for pure convenience is even remotely common. NYT certainly chose some reason charmers to profile! Typical.

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  22. As a twin, this is very difficult to read. How could I have ever trusted my parents again if I learned that they had chosen to abort my sister? The thought is mind-boggling.
    My mother had two very difficult twin pregnancies, right in a row and both conceived spontaneously. She lost the first set at 26 weeks, and we were born premature at 31 weeks. She said that she was SO HAPPY to have us when we were born that she didn't even realize how much work it was to take care of two babies at once. My parents chose not to have more children after my brother was born, because pregnancy was so difficult for my mother. I know that I won't even mention this article to my mother, because the thought of it would be too painful.
    The thought of terminating a child for any reason, especially simply to reduce the number children, is inconceivable to me. If we were unable to look inside with high-tech machines, such a thing wouldn't be possible anyway. Medical science has gone too far with a lot of things.

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  23. It is so shocking to me that people who read a blog all about women's ability to make birth choices for themselves would be so hateful toward women who are making the best choices they can. The choice to birth the way we want is on the same continuum with the choice to not birth at all or to birth fewer children than we become pregnant with. If you can't support women on a different part of the spectrum than you, you can't expect too much support in return.

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  24. I have had friends in three different situations that this brought up for me.

    - one, a mother of two who was unable to access an abortion, which was essential due to her heart condition. She died late in the pregnancy, taking the child with her of course. Her children and husband limp along still years later.

    - another, pregnant from rape, killed herself rather than bear the child. Her parents had locked her in her room so that she would not be able to get an abortion when they found out about it. The rapist was never prosecuted.

    - The third, my sister in law, had to remove one twin when the twin died in utero. It was quite dangerous.

    - And the fourth, a 46 year old who chose selective reduction of triplets when her health deteriorated during the pregnancy. She later gave birth to one still born and one live child. She remains paralysed from the birth and unable to care for the children or go back to work. Of course under current budgets and politics, all of her home health has been cut by 50%.

    None if its pretty. And really, none of it is my own personal choice. I am thankful that I have not had to make these painful choices.

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  25. Society tells me that women have the right to choose an abortion. I am a monster if I say anything opposing that freedom of choice.

    In light of that, I would say selective reduction is a personal choice and I have no right to say anything about it.

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  26. My brother-in-law called today after going to an 8-week ultrasound with his wife. They saw three in there. They are not deciding anything right now, waiting to see a specialist, but the doctor they saw after the ultrasound already mentioned selective reduction. Their instinct is to say no, but they also want to know more about the risks and the probabilities, to sit with this for a while. I don't envy their position. Yes, in some ways it would be easier not to know, so as not to have to decide. But ultimately, I'm glad they get a choice, and I think they are too.

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  27. I am not glad they get a choice to kill one of their three children. The mother should be hastening to make her diet the best she possibly can to grow three babies as healthy as she can get them, as long as she can carry them.

    I know a woman who has triplet brothers. This was in the days before ultrasound. The mother didn't know until she was giving birth! She had three 8 pound boys!

    I know if they have three babies, they will love them all, and grieve if they lose one of them. They would never be able to give one away. So how can you have someone killed, that you know you will love more than your own life in a few months?

    I don't think having a choice, per se, is a good thing. Making good choices, is a good thing. Some choices should be unthinkable.

    Susan Peterson

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  28. "some choices should be unthinkable."
    Exactly!!!

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