Ethics of fetal reduction: a reply to my critics

Journal of Medical Ethics ◽

10.1136/medethics-2021-107725 ◽

2021 ◽

pp. medethics-2021-107725

Author(s):

Joona Räsänen

Keyword(s):

Twin Pregnancy ◽

Original Version ◽

Moral Problem ◽

Singleton Pregnancy ◽

Fetal Reduction ◽

Short Reply ◽

Multifetal Pregnancy ◽

Multifetal Pregnancy Reduction

In the article, Twin pregnancy, fetal reduction and the ‘all or nothing problem’, I argued that there is a moral problem in multifetal pregnancy reduction from a twin to a singleton pregnancy (2-to-1 MFPR). Drawing on Horton’s original version of the ‘all or nothing problem’, I argued that there are two intuitively plausible claims in 2-to-1 MFPR: (1) aborting both fetuses is morally permissible, (2) aborting only one of the twin fetuses is morally wrong. Yet, with the assumption that one should select permissible choice over impermissible choice, the two claims lead to a counter-intuitive conclusion: the woman ought to abort both fetuses rather than only one. It would be odd to promote such a pro-death view. Begović et al discuss my article and offer insightful criticism, claiming, that there is no ‘all or nothing problem’ present in 2-to-1 MFPR. In this short reply, I respond to some of their criticism.

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Twin pregnancy reduction is not an ‘all or nothing’ problem: a response to Räsänen

Journal of Medical Ethics ◽

10.1136/medethics-2021-107363 ◽

2021 ◽

pp. medethics-2021-107363

Author(s):

Dunja Begović ◽

Elizabeth Chloe Romanis ◽

EJ Verweij

Keyword(s):

Decision Making ◽

Twin Pregnancy ◽

Real Life ◽

Singleton Pregnancy ◽

Medical Reason ◽

Fetal Reduction ◽

Multifetal Pregnancy ◽

Life Decision ◽

Multifetal Pregnancy Reduction

In his paper, ‘Twin pregnancy, fetal reduction and the ‘all or nothing problem’, Räsänen sets out to apply Horton’s ‘all or nothing’ problem to the ethics of multifetal pregnancy reduction from a twin to a singleton pregnancy (2-to-1 MFPR). Horton’s problem involves the following scenario: imagine that two children are about to be crushed by a collapsing building. An observer would have three options: do nothing, save one child by allowing their arms to be crushed, or save both by allowing their arms to be crushed. Horton offers two intuitively plausible claims: (1) it is morally permissible not to save either child and (2) it is morally impermissible to save only one of the children, which taken together lead to the problematic conclusion that (3) if an observer does not save both children, then it is better to save neither than save only one. Räsänen applies this problem to the case of 2-to-1 MFPR, arguing ultimately that, in cases where there is no medical reason to reduce, the woman ought to bring both fetuses to term. We will argue that Räsänen does not provide adequate support for the claim, crucial to his argument, that aborting only one of the fetuses in a twin pregnancy is wrong, so the ‘all or nothing’ problem does not arise in this context. Furthermore, we argue that the scenario Räsänen presents is highly unrealistic because of the clinical realities of 2-to-1 MFPR, making his argument of limited use for real-life decision making in this area.

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Twin pregnancy, fetal reduction and the 'all or nothing problem’

Journal of Medical Ethics ◽

10.1136/medethics-2020-106938 ◽

2020 ◽

pp. medethics-2020-106938

Author(s):

Joona Räsänen

Keyword(s):

Moral Theory ◽

Twin Pregnancy ◽

Assisted Reproductive Technologies ◽

Multiple Pregnancy ◽

Reproductive Technologies ◽

In Vitro Fertilisation ◽

Singleton Pregnancy ◽

Fetal Reduction ◽

Health Related

Fetal reduction is the practice of reducing the number of fetuses in a multiple pregnancy, such as quadruplets, to a twin or singleton pregnancy. Use of assisted reproductive technologies increases the likelihood of multiple pregnancies, and many fetal reductions are done after in vitro fertilisation and embryo transfer, either because of social or health-related reasons. In this paper, I apply Joe Horton’s all or nothing problem to the ethics of fetal reduction in the case of a twin pregnancy. I argue that in the case of a twin pregnancy, there are two intuitively plausible claims: (1) abortion is morally permissible, and (2) it is morally wrong to abort just one of the fetuses. But since we should choose morally permissible acts rather than impermissible ones, the two claims lead to another highly implausible claim: the woman ought to abort both fetuses rather than only one. Yet, this does not seem right. A plausible moral theory cannot advocate such a pro-death view. Or can it? I suggest ways to solve this problem and draw implications for each solution.

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Outcomes of transvaginal multifetal pregnancy reduction without injecting potassium chloride

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20164654 ◽

2016 ◽

Vol 6 (1) ◽

pp. 182

Author(s):

Devika Gunasheela ◽

Sneha Rao ◽

Geethika Jain ◽

Anitha GS

Keyword(s):

Birth Weight ◽

Preterm Delivery ◽

Multiple Pregnancy ◽

Reproductive Technologies ◽

Abortion Rate ◽

Control Group ◽

Fetal Reduction ◽

Reduced Group ◽

Multifetal Pregnancy ◽

Multifetal Pregnancy Reduction

Background: Assisted reproductive technologies and the use of fertility drugs have significantly increased the prevalence of multiple pregnancy in last three decades. Various techniques and routes have been studied so far regarding fetal reduction to achieve healthy viable pregnancy. The current study aims to study different outcomes of multifetal pregnancy reduction without injecting potassium chloride.Methods: Total 57 patients were studied from October 2011 to November 2012 at our centre. 28 were higher order pregnancies who consented for fetal reduction and 29 were nonreduced twins as control group. It was a prospective comparative study. Fetal reduction was done transvaginally between 8-12 weeks by intracardiac puncture followed by manual aspiration of embryonic parts till asystole. Use of KCl was avoided. The most easily accessible sac was chosen for reduction. All were reduced to twins. Reduction to singleton and selective reduction of anomalous fetus were removed from the study as it could have created a bias in the comparison. The primary outcomes like miscarriage, post procedure complications, mean gestational age at delivery, preterm delivery, mean birth weight were studied. The outcomes of reduced twins were compared with that of nonreduced twins. The various secondary outcomes like IUGR, take home baby rate, neonatal morbidity, mortality, maternal morbidity and mortality, associated obstetric complications were studied.Results: Both groups were comparable with respect to age and parity. The average gestation of fetal reduction was 9.46 weeks. Abortion rate was 17.9% (n=5) in reduced group which was statistically significant. 4 patients were lost to follow up. There were no statistically significant differences with regard to cesarean section rate, preterm delivery, mean birth weight, mean gestational delivery between two groups. No incidence of IUGR in the series. One baby died in the control group, none in reduced group. Take home baby rate 79.1%. Overall the antenatal and post-operative complications were higher in control group than in reduced but it was not statistically significant.Conclusions: Fetal reduction is a feasible option for triplets and higher orders multiple pregnancies. Use of KCl is not mandatory for multifetal pregnancy reduction. It is best avoided as there are increased rates of preterm labour and PPROM. There is increase in abortion rate after multifetal pregnancy reduction in comparison to nonreduced twins. So couple should be counseled about the probability of losing the entire pregnancy. The obstetric and neonatal outcomes of reduced and nonreduced twins are comparable, thus fetal reduction as a procedure is not adding any extra risk on pregnancy outcome.

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Outcome of Multifetal Pregnancy Reduction in Women with a Dichorionic Triamniotic Triplet Pregnancy to a Singleton Pregnancy: A Retrospective Nationwide Cohort Study

Fetal Diagnosis and Therapy ◽

10.1159/000441650 ◽

2015 ◽

Vol 40 (2) ◽

pp. 94-99 ◽

Cited By ~ 9

Author(s):

L. van de Mheen ◽

S.M.P. Everwijn ◽

M.C. Haak ◽

G.T.R. Manten ◽

H.A. Zondervan ◽

...

Keyword(s):

Cohort Study ◽

Gestational Age ◽

Survival Rates ◽

Triplet Pregnancy ◽

Singleton Pregnancy ◽

Gestational Age At Delivery ◽

Gestational Age At Birth ◽

Multifetal Pregnancy ◽

Perinatal Survival ◽

Multifetal Pregnancy Reduction

Objective: To study the pregnancy outcomes of women with a dichorionic triamniotic triplet pregnancy that was reduced to a singleton pregnancy and to review the literature. Methods: We performed a nationwide retrospective cohort study. We compared time to delivery and perinatal mortality in dichorionic triplet pregnancies reduced to singletons with ongoing dichorionic triplet pregnancies and primary singleton pregnancies. Additionally, we reviewed the literature on the subject. Results: We studied 46 women with a reduced dichorionic triplet pregnancy and 42 women with an ongoing dichorionic triplet pregnancy. Median gestational age at delivery was 38.7 vs. 32.8 weeks, respectively (p < 0.001). Delivery <24 weeks occurred in 9 (19.6%) women with a reduced triplet pregnancy and 4 (9.5%) with an ongoing triplet pregnancy (p = 0.19). Perinatal survival rates between the reduced group and the ongoing triplet group were not significantly different. Conclusion: Multifetal pregnancy reduction in women with a dichorionic triplet pregnancy to a singleton pregnancy prolongs median gestational age at birth. No statistically significant association was found with miscarriage and perinatal survival rates.

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