Multiple Pregnancies and

Selective Reduction
Nursing 405 Ethics Hot Topics
Jessica Listman-Ward
Frostburg State University

Multiple Pregnancies and Selective Reduction

Multiple Pregnancies and Selective Reduction

Introduction

When making a decision people rely on their morals and the law. Law is defined as a
rule of conduct or action prescribed or formally recognized as binding or enforced by a
controlling authority (Merriam-Webster, 2013). Laws are written and generally do not change.
This makes them easier to understand than morals. Morals however, are unique for each
person. Everyone has their own individual set of morals and beliefs. These depend on an
individuals religion, upbringing and personal values. A persons morals and beliefs can change
throughout their lifetime. Morals are what allow us to make decisions on what is right or
wrong (Merriam-Webster, 2013). When making decisions about another life both the law and
ethics come into play.
The Law
When we think about the idea of multiple pregnancies and selective reduction it can
strike a nerve with some people. Are we playing God by giving people medication to make it
easier for them to have children? It does not seem natural that we are manipulating a womans
body to allow a conception to happen. Do we know how safe this can be to the woman in the
long run? These are some of the questions that come up when Ive asked people their thoughts
on the topic. These questions can be applied to both the legal and ethical issues of multiple
pregnancies and selective reduction.

Multiple Pregnancies and Selective Reduction

While it is true that we are manipulating a womans body to allow for conception, there
are no laws that prevent this. In fact one of the risks of using fertility medications is multiple
pregnancies (Mayo Clinic Staff, 2013). Doctors counsel patients on the risks before they begin
the treatment to help prepare them for the risk of multiple pregnancies. They also avoid them
whenever possible. In fact The American Congress of Obstetricians and Gynecologists (2013)
states that the first approach to the problem of multifetal pregnancies, should be prevention,
and strategies to limit multifetal pregnancies (p. 405). They strongly recommend avoiding
multiple pregnancies for many reasons, one of which being maternal safety.
Doctors take an oath which states that they will do no harm. In order to prevent harm
to their patient, in this case the mother, doctors sometimes need to reduce the number of
pregnancies. They rely on the Roe v. Wade decision to justify reductive selection. Roe v. Wade
allows a woman to have the right to make a decision to end a pregnancy (Pozgar, 2013, p. 73).
This well-known case made it legal for abortions to occur within the United States. When a
mother is carrying multiple fetuses it can be dangerous to both her and the babies she is
carrying. With this in mind they counsel the patient in making a decision that will benefit her
and her unborn children. There is a greater risk to both the mother and the fetuses throughout
the pregnancy if reduction is not done.
Women carrying multiples are at a great risk for a spontaneous miscarriage,
preeclampsia, gestational diabetes, postpartum hemorrhage, kidney and/or liver damage
(Shepelavy, 2009, p. 1). In addition there are also risks for the babies, which include premature
delivery, cerebral palsy, learning deficits/disabilities, lung disease and/or death (American

Multiple Pregnancies and Selective Reduction

College of Obstetricians and Gynecologists, 2013, p. 408). This is the reason that doctors can
justify ending one life to save another. If mothers do no choose to reduce the number of
fetuses they place everyone at a greater risk of death. Statistics show the risk of miscarriage is
25% for quadruplets and 8% for twins (American College of Obstetricians and Gynecologists,
2013, p. 408). This is a significant difference, and one can see that as the number of fetuses
increases so does the risk. Doctors take the oath of do no harm seriously. They want to try and
avoid and harm to their patient and their unborn children. While informing a patient that they
must go from carrying five fetuses to two or three is never easy they know that they are
preventing harm to her and the surviving fetuses.
The Ethics
The questions that were asked above can be applied to the ethics of reducing a
pregnancy. It is true that in a way we are playing God by allowing a woman who has trouble
conceiving to use fertility drugs to have a baby. Many would say that it is Gods will that a
woman not conceive if she is having trouble. We are interfering with nature when we use
science to help a woman start a family. Others would say that there are plenty of children who
need homes and adoption is an option. This solves the problem of starting a family, but most
women want the experience of being pregnant with their own child.
People view selective reduction in the same way as they do abortion. It brings up mixed
feelings. There are some who think that it is ok because it is in the best interest of the mother.
The selective reduction will reduce the risks for the mother which will make it safer for her to
carry her other children to full term. However, we are still using potassium chloride to stop the
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Multiple Pregnancies and Selective Reduction

hearts of fetuses (Shepelavy, 2009, p. 1). There are those who are anti-abortion and view this
as murder.
We must also think about the long term effects for the family who must make this
decision. While we can see that it is recommended for the safety of everyone, it is still a
difficult choice, and one that remains forever. Once the heart is stopped in utero it cant begin
to beat again. Therefore this decision is permanent.
There are many ethical viewpoints on how to decide and deal with the decision after it
occurs. We must make sure that the procedure is being done for the right reasons. There are
people who use assisted reproductive technology (ART) to have a baby that is a specific gender.
As we know there is a greater risk of multiples any time we use technology or medications for
pregnancy. Most people would say that it is wrong to terminate a fetus based on the sex.
While these cases do not happen often, they still exist and are frowned upon by The American
College of Obstetricians and Gynecologists (p. 410). In addition reducing a pregnancy to a
single birth because the family doesnt feel that they can handle twins is viewed as wrong.
When we look at reducing births, it is typically because there are more than 3 fetuses
(American College of Obstetricians and Gynecologists, 2013, p. 410). To reduce a pregnancy
because the family doesnt feel that they have room for another baby or can financially afford
one is not a justifiable reason to perform the procedure.
As a medical profession we must respect a patients right to make decision about their
own health. Patients have the right to autonomy (Pozgar, 2013, p. 14). Medical professionals
must inform them on the issue at hand, but the patients have the ability to decide what will be
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Multiple Pregnancies and Selective Reduction

best for themselves. Women are able to have their own viewpoints and make choices on their
pregnancy based on their values and their beliefs. Doctors cant force them to reduce the
number of fetuses, but they are required to provide them with the risks and benefits of the
procedure (American College of Obstetricians and Gynecologist, 2013, p. 408). With this in
mind it is ultimately that womans decision on whether or not to have the procedure.
Doctors are required to follows the ethical principle of nonmaleficence. This principle
states that caregivers avoid causing harm to the patient (Pozgar, 2013, p. 13). This is why the
oath includes do no harm. This principle only applies to the patient. When a doctor selectively
reduces a pregnancy, they are stopping the hearts of the fetuses in order to protect the health
and wellbeing of the mother.
This principle goes hand in hand with beneficence. Beneficence is the principle of
doing good, demonstrating kindness, showing compassion, and helping others (Pozgar, 2013,
p. 9). By protecting the health and welfare of the mother doctors are showing beneficence.
There are people who will argue that a doctor shows neither of these when performing a
selective reduction since they are still causing harm to the fetuses. Its not a black and white
decision.
Whats the right decision?
We live in a society where both viewpoints can be argued. The goal is to save the
patient and ensure a healthy delivery. We know that even having one child can pose a risk to
the healthiest of mothers, so imagine carrying multiples and the toll that can take on the body.
We ultimately want the best possible outcome for our patient. It is not an easy decision to
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Multiple Pregnancies and Selective Reduction

reduce some of the fetuses, but it is the one that allows the best outcome for mother and
babies. As I have stated this decision is final and the mother must live with it forever. It can
carry an emotional and psychological burden for some mothers.
I myself went through something similar to this a few years ago. Unbeknownst to me I
had an ectopic pregnancy. It was discovered when I went to the doctor for excruciating
abdominal pain. Strangely enough the fetus did not die early on, like most do. Since these
types of pregnancy can be very dangerous to women, my doctor informed me that it would be
in my best interest to terminate my pregnancy. I agreed since the risk of death is high with
these cases. Looking back I know that the decision was the right one to make, however I was
plagued with emotional guilt for a long time. I can only imagine the toll that reductive selection
can take on a woman.
I think that early education and counseling are a good way to prepare a woman for
what they may expect. In addition doctors need to use fewer embryos to avoid multiple
pregnancies. While we know that not every embryo will implant, we do not need to put in 6 or
7 fertilized eggs. We can work with 2 or 3 and get a single pregnancy, or at the very least only
work with triplets at most. This will help decrease the need for selective reduction.
I can understand how people can say that selective reduction can cause harm to the
mother. While it is easy to understand that a mother is putting her life at risk by carrying so
many fetuses, so a decision must be made for her safety, it is harder to understand the
emotional toll that can occur with ending multiple pregnancies. This is something that science
cant measure and is unique for each patient.
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Multiple Pregnancies and Selective Reduction

I agree that selective reduction for the safety of the mother and other fetuses is a good
idea. We just need to prepare the mother for the possibility that this decision may need to
occur. We also need to provide support afterwards. If we provide counseling and resources to
the mother we can help her face the emotional consequences of terminating some of the
fetuses. We as a society need to understand that it is an individual decision and we must
respect that.
Overall I think that doctors must provide good teaching throughout any assisted
reproduction to prepare people for all possible outcomes. I am not against reductive selection
if it is done for the right reasons. I do not think that reducing a pregnancy because you want a
specific gender or cant handle twins should be allowed. If you had conceived in a natural way
without drugs you wouldnt get to choose how many children you had or their sex. These
things are determined at conception. If the selection is done to protect the mother, then that is
a different story. We want a happy ending for all couples. If reducing a pregnancy of sextuplets
to triplets decreases the risks for both mother and the remaining three fetuses than it is the
right decision. Choosing to end the lives of some of the fetuses, but not all is a difficult decision
and one that must be made individually. Each person and their situation are unique. Nobody
has the right to judge another until they have walked in their shoes. Having said this I think that
everyone has the right to make their own decision. The woman is the one who is carrying the
children and taking the risks. I just think that she needs to be well educated on all of the
options and has given her decision some thought.

Multiple Pregnancies and Selective Reduction

References:
American College of Obstetricians and Gynecologist. (2013). Multifetal Pregnancy
Reduction: A Committee Opinion. Obstetrics Gynecology, 121, 405-410
Clinic Staff, (2013). Infertility Treatment and Drugs. Mayo Clinic. Retrieved from
http://www.mayoclinic.com/health/infertility/DS00310/DESECTION=treatmentsand-drugs
Merriam-Webster. (2013). Law. Merriam-Webster. Retrieved from
http://www.merriam-webster.com/dictionary/law
Merriam-Webster. (2013). Moral. Merriam-Webster. Retrieved from
http://www.merriam-webster.com/dictionary/moral
Pozgar, G. D. (2013). Legal and Ethical Issues for Health Professionals (3rd). Burlington,
MA: Jones & Bartlett Learning.
Shepelavy, R. (2009). When fertility treatments become frightening. Pregnancy.
Retrieved from http://www.nbcnews.com/id/30013982/ns/health-pregnancy/
t/when-fertility-treatments-become-frightening/#.Uqsllzix6M8