Selective Reduction: Abortion by Another Name

Newborn twins with mother on table
Estimated reading time: 7 minutes

Recently, we’ve gotten comments asking us to address whether or not “selective reduction” is an ethical practice (or perhaps more to the point, to explain why it is not). On one hand, this makes sense; we don’t have material specifically addressing selective reduction or assisted reproductive technologies, and it’s worth talking about those things in detail. On the other hand, I’m a bit surprised, because selective reduction is just an abortion being performed in a specific context that still fails to provide a justification for killing.

What Is Selective Reduction?

Selective reduction is the practice of “treating” a multiple pregnancy—when a woman is pregnant with twins, triplets, etc.—by “reducing” the number of live embryos or fetuses. The method of reduction is, of course, a surgical abortion, a violent method used to end the life of a prenatal human. It’s especially barbaric in this context, given that it kills one sibling as it gestates next to another.

Take this example, excerpted from our podcast episode on fetal pain:

[T]his happened during what is called a selective reduction. It was a woman who was pregnant with triplets. They were trying to reduce the triplets down to just twins. During this procedure what happens is a long needle is inserted through the maternal abdomen, through the uterus, and the needle then has to penetrate through the chest into the heart of the fetus, and inject a lethal medication. 

As this radiologist watched this procedure, what happened was that as the needle touched the chest of this fetus who was less than 18 weeks gestation, there was immediate flailing and as the radiologist described it, this fetus was fighting for its life. So, the person doing the procedure, the OB/GYN, attempting to do this procedure, had to try two or three more times because the fetus kept moving away, and again, flailing at each attempt. They actually had to then move the needle to a different fetus and were eventually successful. 

I think another compelling part of that testimony was that during the procedure, the monitor was turned toward the pregnant woman, and she just broke into tears as she watched the reaction of the fetus on the screen and the technician was told to move the screen away so that she could not view it.

While this should be viewed uncontroversially as a barbaric and indefensible practice, many people in the fertility field are quite comfortable with selective reduction and view it as not only acceptable but medically indicated. In order to show that selective reduction is a justifiable practice, one would have to make the case that the conditions of a multiple pregnancy are sufficient to excuse an action designed to take the life of an unborn human. Proponents of selective reduction fail to do this. But before we take a look at the best possible justification for selective reduction, we should look at why there are enough multiple pregnancies to make this a prominent ethical issue in the first place.

Selective Reduction and the “Wild West” of IVF

Fertility treatments are a big business in the United States. The most well-known fertility treatment is in vitro fertilization (IVF), in which eggs are extracted from a woman and artificially inseminated in a laboratory setting before being reimplanted in the woman. IVF currently accounts for about 80,000 children born each year in the United States, which is about two percent of all births. There are plenty of ethical issues with IVF—the freezing/thawing process which results in the death of 10 to 35 percent of embryos, risks associated with drugs given to stimulate egg production, the lack of basic quality controls—but the most important one for our analysis is the intersection of the desire for children and profit motive.

One cycle of IVF (basically, one attempt at producing a live birth through all the components of the treatment) costs between $15,000 and $30,000. But that doesn’t mean $20,000 gets you a baby; it gets you a chance at a baby. And it’s not a particularly high chance: in 2020, there was about a 23 percent chance that a given cycle of IVF would result in a live birth. If you put all the numbers together, you end up with a US IVF market that was worth almost 17 billion dollars in 2018.

The high desire for a baby combined with lack of regulation has turned IVF, specifically, into a “wild West” environment. There are no meaningful enforceable standards, and so not all decisions are made with the interests of the mother at heart, let alone the commodified children created by the process. Given the low chance of a successful pregnancy, IVF clinics frequently implant multiple embryos in the hopes that at least one will make it to term. In one study, an average of almost three embryos were implanted per cycle, with some patients having as many as six embryos implanted.

Frequently, either one or zero embryos will survive this process; but given 325,000 attempts per year, there are many instances in which multiple embryos successfully implant. This high level of IVF usage has contributed to an increase in multiple pregnancies, leading to such sensational cases as “Octomom,” the woman who gave birth to the first octuplets on record after her doctor transferred 12 embryos into her uterus. While octuplets are a far outlier, twins and triplets are relatively common, and, because multiple pregnancy increases some risks to both mother and children, IVF clinics often recommend selective reduction as a solution to the multiple pregnancy problem they created.

Do Increased Risks Justify Selective Reduction?

Multiple pregnancy does increase risks of complications and mortality for mothers, as well as the children. That means the most likely way to justify selective reduction is by appealing to self-defense; if the mother’s life is at stake, then pro-life and pro-choice people agree that some interventions would be appropriate, even if it results in the death of the child.

The problem is, like almost every situation in which pro-choice people try to invoke self-defense, multiple pregnancy does not present the sort of risk to the mother that would justify taking an innocent life. Even granting, as one paper asserts, that maternal mortality is three times higher in multiple pregnancies than pregnancies with a single fetus, the mortality rate is still well under a tenth of a percent. In Europe, before the year 2000, it was .0149 percent; even in Sudan, which has a much higher overall maternal mortality rate, it was .0358 percent for twins and .099 percent for triplets. And that’s without another 20 years of improvements in perinatal technology to improve outcomes for mothers and children! As we’ve said elsewhere, it may not be clear exactly where to draw the line where a risk to your life is sufficient to take lethal action, but it’s certainly above one percent. Even with the increased maternal mortality risks of multiple pregnancy, it’s not even close to one percent.

Granted, there could be an individual situation in which the risk to the mother (and therefore also to her children) was sufficiently high to render it a life-of-the-mother case. In this case, it would be appropriate to take actions to save the lives of as many people as possible, even if it results in death for some. But that’s not how selective reduction is used; the extreme outlier cannot justify the self-defense claim in general.

Let’s take a detour for a moment to address the idea that increased risk to the children could justify selective reduction. After all, the infant mortality rate for twins in the UK is five times higher than for singletons. If we don’t kill one child, the argument goes, then all of them are at risk of dying. But that rate that’s five times higher? It’s a two percent risk of infant mortality; unacceptably high, but not a good justification for killing someone. It makes zero sense from the perspective of triage to inflict a 100 percent chance of death on one person to mitigate a two percent chance of death to two people.

Neonatal complications for the children are insufficient to justify selective reduction, so the only possible out is a life-of-the-mother situation. Multiple pregnancy is not inherently a life-of-the-mother situation, so the self-defense justification fails. Selective reduction remains merely a euphemism for a wrongful abortion.

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Writer / Researcher

Andrew Kaake (pronounced like “cake”) is the Lead Editor at Equal Rights Institute. He holds a bachelor’s degree in classics and political science, cum laude, from Amherst College, where he wrote a thesis on the topic of C.S. Lewis and natural law philosophy. He completed his master’s degree in bioethics at Trinity International University, studying the philosophical underpinnings of controversies about life, death, and technology and trying to create ways to communicate that information to others. During his studies at Trinity, he worked as a research assistant for The Center for Bioethics & Human Dignity.

Andrew wants the pro-life movement to help foster a culture that seeks truth and embraces logical consistency. “What I believe about humanity and personhood clearly impacts what I think about abortion, but it also holds implications for how I should (and, more importantly, shouldn’t) dialogue with other people who disagree with me.”

Andrew blogs about theology and other topics at andrewkaake.com

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