“We believe that even a single fetal reduction is ethically questionable and that the practice should not be in use at all”

One of the main consequences of the use of In Vitro Fertilization is the significant increase in multiple pregnancies; however, this can also be caused by ovarian stimulation and intrauterine insemination.

It is widely known that multiple pregnancies increase the risk of suffering from other medical problems in both mothers and their fetuses.

That is why the number of implanted embryos is often regulated in order to reduce the number of multiple pregnancies, especially when there is no decrease in the rate of pregnancy and live births with single embryo transfer, when compared to multiple embryo transfer (Fertil Steril 95; 491, 2010), although not all experts are in agreement on this fact.

As a consequence, some countries have passed laws which regulate the number of embryos that can be transferred, limiting them to no more than two or three. Other countries do not have any regulations to this effect.

At any rate, it is clear that multiple pregnancies still occur and the way to “solve” this issue is to try to reduce the number of fetuses in order to increase the survival rate of those which remain after said reduction.

See our Special Report Biological status of embryo  HERE 

But before we continue, it is important to first understand what we mean when we say fetus reduction as opposed to selective termination (Reproductive BioMedicine Online, 26; 542-554, 2013). The latter term refers to eliminating fetuses which suffer from some medical condition, Down Syndrome in particular while the first term refers to the elimination of healthy fetuses, and its only aim is to “solve” the problem of multiple pregnancies.

In general, it is the pregnant woman who is ethically responsible for choosing whether to carry out a fetus reduction, a choice in keeping with the principle of personal freedom (Health Care Arial 9; 167-185, 2001). However, from a utilitarian bioethical perspective, this goes against the inalienable right to life of the fetuses that are eliminated – a consideration which makes this practice the object of significant ethical debate.

Fetuses growing in their mother’s womb considered as being passengers in a lifeboat

At times, the ethical assessment of embryo reduction has been equated with so-called “lifeboat ethics”, which considers fetuses growing in their mother’s womb as being passengers in a lifeboat. In both situations, there is insufficient space and resources which mean that not all will be able to survive. In this sense, it sounds like a good idea to eliminate some to ensure the survival of the remaining foetus or foetuses. However, we believe that these two scenarios are radically different. In the lifeboat scenario, a certain number of people occupy the vessel because it is the only means of survival under a given set of circumstances imposed upon them; in the case of a multiple pregnancies, this situation is the result of a medical decision made in part by the mother to implant a high number of embryos to ensure efficacy of IVF.  This clearly represents a utilitarian perspective; it would have been just as effective to transfer one or two embryos which would have prevented this situation altogether.

Regardless of the debate incited by this issue, it is a practice that is frequently used in obstetrics clinics.

For instance, in the United Kingdom, the number of fetal reductions varies from 15 and 191 per year; the latest data shows that in 2010, 85 such procedures were performed. Given that the number of multiple births in 2011 exceeded 11,000, 85 fetal reductions represent a small proportion (Reproductive BioMedicine Online 26; 522-524, 2013). However, we believe that even a single fetal reduction is ethically questionable and that the practice should not be in use at all.

 

Justo Aznar
Bioethics Observatory