Tuesday, May 29, 2007

Selective Reduction

Liz Mundy of the Washington Post recently wrote one of the most honest and unbiased portrayals of abortion I've ever read. She writes about abortion in the context of assistive reproductive technologies like IVF and makes it no secret that she is in favor of such technologies. Her views on abortion in this context are complex. She makes it no secret that she is uncomfortable with some aspects of selective reduction (e.g., gender selection), but at the same time she says to another couple experiencing doubt about their past decision, "clearly, you made the best, most responsible choice that you could."

I would highly recommend reading the entire article and follow-on Q&A forum.
http://www.washingtonpost.com/wp-dyn/content/article/2007/05/15/AR2007051501730.html
http://www.washingtonpost.com/wp-dyn/content/discussion/2007/05/18/DI2007051801515.html
If these don't work try searching for "selective reduction" on the washington post website and don't forget bugmenot.com if you're in a rush and they ask for a username/password.

Most interesting aspects of the article for me.
1) The role of gender selection in many of the abortions
2) The role of apparent coercion in one of the stories. This was especially poignant to me given the role of parental coercion in the abortion of someone I know.
3) The discomfort of many radically pro-abortion people when faced with this procedure in their own lives vs. abortion in the case of unwanted pregancies.
4) The potential psychological side effects when it comes to bonding with the remaining 'chosen' children
5) The denial by the nurse assisting the doctor that what they were doing was really an abortion and her insistence that she could never assist at real abortions.
6) The reactions of one lady in particular when she realized the reality of fetal development. I'll post a bit of it here as a teaser.

"Oh, my God, I can really see it!" the patient cried. "Oh, my God! I can see the fingers!"

"Okay!" she said, abruptly, gesturing for the screen to be turned away. She began sobbing. There were no tissues in the room, so her husband gave her a paper towel, which she crumpled to her face. The patient spent the rest of the procedure with her hospital gown over her face, so she would not see any more of what was happening.

Even though she had this reaction, she went through with the real procedure the next day.

Like I said earlier, it is a fascinating and amazingly honest look at selective reduction from a big IVF proponent.

MB

18 comments:

MamasBoy said...

Oh, I forgot about the comment by the nurse that "I sometimes feel like we are playing God, and that is very emotionally stressful." She's Jewish.

Here's another quote from the nurse, "It's a very hard procedure, because the baby is moving, and you are chasing it. That is what is very emotional -- when the baby is moving and you are chasing it."

And this quote from the doctor.
"I've come to look at it as: The finished product has a much better chance of surviving," replied Evans, who had been following the conversation intently. "Look, you never want to dehumanize it, because then you get cavalier. You have to keep the big picture in mind. We're not losing one. We're saving some."

So, the result is a product, but in the very next sentence he states that you don't want to dehumanize it. Also, it seems to me, that even though one is increasing the chances of carrying a single baby to term, clearly deaths are taking place. To say that "we aren't losing one" is dishonest. The number of live births and children born has clearly dropped. This is glaringly true in the case of selective reduction for twins, which Evans does.

The nurse seems so close admitting the wrong, yet she can't bring herself to do so.

The reason I think there is so much more honesty about the procedure than abortion in general is that there is so much more personal involvement from the doctor to the parents. The doctor has to be so much more involved because he isn't just emptying the contents of the uterus, he is picking out particular fetuses to kill while leaving the others to grow in as normal an environment as possible. The parents are more involved because they have to make the decision about how many to keep and what criteria to use for killing the others. Then they have to live with those consequences, be they reduced outcomes for the remaining twins/triplets vs. twins/triplets that started that way or just the living reminder in their surviving children that they had their brother(s)/sister(s) killed in-utero. I know from talking to people who have had abortions and reading that children of the age their child would have been and future pregancies can bring back memories. What will these women and men experience with such living reminders of their decisions?

MB

Kevin said...

I didn't expect to read all of the Q&A and the article, but I did. They were fascinating. Thanks for sharing.

It does seem morally equivalent to abortion, and I'm glad to see the movement to reduce the number of embryos implanted in order to decrease the need to even consider selective reductions.

Do you think selective reduction is ever moral? e.g. in the case of a natural pregancy with high risk, where killing one would save the others?

Do you think there are any cases where IVF is not immoral?

Kevin

MamasBoy said...

Kevin,

I hadn't expected to read the entire Q&A either and was surprised when I did. Off topic, thanks for the further info about taxes and the immigration bill and also your other post. I haven't been keeping up on the immigration bill, so it was nice to read a brief summary.

Regarding your two questions.
1) Is selective reduction ever moral?
- To be honest, I'm not positive, but I heavily lean toward no. For one, I don't understand the math Dr. Evans was using in these cases. It seems to run something like, if we can increase the chance of survival by 5% for 1-2 kids, then it is OK to decrease the chance of survival by 100% for the rest. They are obviously taking a vastly greater number of lives than they claim to be saving.

For another, when "abortion" is ethical, it is in the form of an indirect abortion where the mother and her child would die if nothing were done. These are pretty rare cases like ectopic pregnancy, cancer of the uterus, and uterine trauma. Also, when possible, every effort should be made to save both lives.

2) Do I think that IVF is ever moral?
This is completely outside the scope of the original post, but since you ask my opinion on the topic, I will answer. No, on several levels. For one, when IVF is conducted, extra embryos are created and then basically thrown away or used for experimentation. This happens with every single IVF procedure that occurs in this country. The desire of couples to be parents does not justify the wanton destruction of human life.

In addition, every child deserves to be the result of an act of love between his or her parents. God created intercourse and procreation to go together. Just as it is wrong to have sex and purposefully frustrate its natural end in procreation (i.e., to contracept), even so it is wrong to remove the act of love between husband and wife from the process of procreation.

I hope this doesn't sound callous to the pain of infertility, because I know that the pain is real and deep for many couples. My wife and I saw some friends tonight after a movie who have been trying for over a decade to conceive. They both turned forty within the past few years and given their history, statistically their chances of ever having a child have been getting extremely slim. It has been hard to see their pain. My wife and I have offered referrals and said many a prayer for them in their difficulty. This evening, while talking on the sidewalk outside the theater, they told us that their miracle baby is due Sept. 17. I don't know why God allowed them to have such a long season of infertility while they watched their friends raise children, but we thank Him for generously blessing them with this baby. My friend have been so active in coordinating various ministries for the church in Albuquerque. Their presence will be sorely missed, but who would not be glad that they are going to have a chance to cut back and focus on raising their child. If God wants those ministries to continue, he will provide other people to coordinate them.

MB

Kevin said...

MamasBoy,

MB: "1) Is selective reduction ever moral?
- To be honest, I'm not positive, but I heavily lean toward no. For one, I don't understand the math Dr. Evans was using in these cases. It seems to run something like, if we can increase the chance of survival by 5% for 1-2 kids, then it is OK to decrease the chance of survival by 100% for the rest. They are obviously taking a vastly greater number of lives than they claim to be saving.
"

Even the statistics themselves seem a little goofy. Maybe they are specially calculated per patient idiosyncracies, but it seems to give the following reductions with pregnancy loss rates:

4 (25%) to 2 (7%)
3 (15%) to 2 (4%)
2 (8%) to 1 (4%)

In any case, I think we would need other statistics to derive whether more kids are living versus dying, such as the effects of parents retrying after failure, higher order pregnancies, natural reduction (I assume it can occur), and maybe even disabilities. But I think you're right that Dr. Evans isn't basing his judgement solely on saving lives.

If the math was used to save more kids than lost, then you might classify it as moral?

Do you think this math should extend to women who are inherently predisposed to high risk pregnancies or miscarriages? i.e. are they morally obligated not to try to have children?

MB: "2) Do I think that IVF is ever moral?
This is completely outside the scope of the original post, but since you ask my opinion on the topic, I will answer. No, on several levels.
"

Thanks for your answer. I can see how it is a bit off-topic, but since it seems to be a (common?) cause for selective reductions, I thought it was related.

In theory, your first concern of extra embryos could eventually be eliminated through technological advancements, but your second concern regarding the normal physical act of love seems to be inherently incompatible with IVF. Do you think other fertility treatments which maintain the act of love are moral?

You know, I'm getting a flashback of a thread on Mark's xanga site. Sorry if we're rehashing the same issue.

P.S. I'm happy you found my immigration post to be informative. Thanks.

Kevin

MamasBoy said...

Kevin,

I'll try to answer your questions. I do have a favor to ask, though: that you answer some of them yourself. I'm really curious as to what you think and why.

First a comment:
4 (25%) to 2 (7%)
3 (15%) to 2 (4%)
2 (8%) to 1 (4%)

The above table doesn't make sense to me because (if I understand it correctly), the (##%) number is a miscarriage or loss rate and the other number is the number of fetuses in utero. We know that normal twins are healthier on average than reduced twins and have higher rates of being carried to term. The above table seems to contradict that, but I rather doubt I'm understanding it properly.

K: "If the math was used to save more kids than lost, then you might classify it as moral?"
MB: Then it would be a much tougher call for me. You are asking a question that I'm not really sure the answer to. I would hesitate to say yes, because I'm not sure that it is ever justified to actively take human life as the primary solution to a problem. I see a difference between treating a problem where the side effect is harming someone and harming someone as the treatement. I'll throw out some psychotic situation as an insufficient analogy to try and illustrate my difficulty. If someone handed me a gun and said kill that person sitting down over there or I will kill 100 people, I don't think I would follow through. On the other hand, if train full of 100 people was headed toward a precipace, but I could save them by diverting the train to another track where a kid was tied up, I would divert the train. The kid dying is a byproduct of me trying to save lives. That's a really poor example, but I think it kind of gets at the dilemna of murder as treatment or death as a byproduct of treatment.

K: "Do you think this math should extend to women who are inherently predisposed to high risk pregnancies or miscarriages? i.e. are they morally obligated not to try to have children?"
MB: I think that women and men are morally obliged to do no harm to kids. This means women shouldn't do drugs, men shouldn't hit women's stomachs, etc. (of course, hitting a woman is itself heinous, but hitting a pregnant woman is especially heinous).

If I am understanding your question correctly, I don't think this can be extrapolated to women conceiving who are in higher risk circumstances (like older women conceiving for the first time). Every pregnancy has risk associated with it. The only way to completely avoid risk is to avoid pregnancy. As long as somebody isn't actively trying to end the pregnancy, I don't think that we can say to somebody, "You've had 5 miscarriages in the last 5 years, you are a high risk case and need to stop trying to have kids." I get the feeling I missed the gist of your question, so hopefully you'll straighten me out if I did.

K: "Do you think other fertility treatments which maintain the act of love are moral?"
Short answer. Yes, I don't have a problem with the idea of fertility treatments that assist conception as a result of the marital act. And the good news is that the medical practices with the highest success rates in helping clinically infertile couples conceive are doing this. Perhaps the tables will be reversed in the future, but that's the way it looks now.
http://www.zenit.org/english/visualizza.phtml?sid=56953

MB

Kevin said...

MamasBoy,

Sure, I'll try to answer those questions as well. Admittedly, though, they are tough questions. :) Let me know if I miss any you are interested in.

In general, I agree with your moral answers as the ideal -- meaning, what I myself would pursue. I don't consider IVF to be inherently immoral, though some details and intent behind it could be. I do not believe I would choose it.

I would avoid selective reduction except in cases where there is a good chance it would save lives. However, I have never actually been faced with making such decisions and I feel they are generally best avoided.

MB: "The above table doesn't make sense to me ..."

I think you are interpreting the table the same way I am: it doesn't quite make sense from a generalized standpoint. Perhaps it is only valid per patient. I extracted it from the original WP article you linked. You can search for the word "percent" in the article to locate them.

MB: "That's a really poor example, but I think it kind of gets at the dilemna of murder as treatment or death as a byproduct of treatment."

It seems you are primarily concerned with whether the danger is deterministic or perhaps whether the statistics are specifically applicable to the patient. You want greater certainty that each life saved is real and not just broadly statistical. Fair enough.

MB: "As long as somebody isn't actively trying to end the pregnancy, I don't think that we can say to somebody, "You've had 5 miscarriages in the last 5 years, you are a high risk case and need to stop trying to have kids." I get the feeling I missed the gist of your question, so hopefully you'll straighten me out if I did."

You understood my question correctly. The dilemma is whether it is moral to knowingly and naturally go through a string of dead embryos to obtain a successful birth. In theory, there might even come a point at which artificial treatments might save more embryos.

I agree with your moral conclusion, which is what leads me away from judging IVF, et al., to be immoral with any certainty. I guess I don't place as great an emphasis on "artificial" being immoral, though by degree I would generally say that "natural" is better.

MB: "Yes, I don't have a problem with the idea of fertility treatments that assist conception as a result of the marital act. And the good news is that the medical practices with the highest success rates in helping clinically infertile couples conceive are doing this."

That is good news; thanks for sharing it.

Kevin

MamasBoy said...

Kevin,

Thanks very much for sharing your perspective. Work and family life are busy right now, so I don't currently have time to pursue this or the other discussions, but I wanted you to know that I'm not just ignoring you. You made a good point about circumcision, etc. on the other post and I want to give it the attention it deserves.

Doug

Kevin said...

Thanks, Doug. No rush. :)

Anonymous said...

The ignorance expounded upon IVF through Media misinformation just knows no bounds. The fact checking by reporters on this topic is woefully lacking. (CDC has all the facts laid out pretty well so that anyone can see that reporters have become, well, just plain lazy in their research.)

The most common reason for Fetal Reduction surgery comes when IVF is not available. You see, IUIs - a more common and older, accepted treatment - are the most likely cause of Higher Order Multiples resulting in Fetal Reduction.

No ethical doctor will transfer so many embryos if s/he believes that there is a high likelihood of a HOM pregnancy occurring.

Most people do not even begin to understand what is involved in creating a pregnancy.

IVF diminishes the need for fetal reduction.
IUI increases the need for fetal reducion.

It really is that simple.

Oh, and to over 3 embryos being transferred? That really only occurs in older patients who are less likely to have a successful transfer. (Implantation does not occur when the doctor transfers the embryo to the uterus. This is part of the reason that there is a slightly higher risk for ectopic pregnancies.)

Speaking of ectopic pregnancies. These are ended by abortions. Don't use semantics to deny this either. IUIs which result in HOMs are also very likely to result in ectopic pregnancies which often need to be ended for the sake of anyone surviving the pregnancy.

Oh, and pregnancy never was, and never will be, 100% safe.

Kevin said...

Anonymous,

Thanks for your comments.

Do you have a link to a good summary of CDC stats? I found the CDC's 2004 Assisted Reproductive Technology (ART) Report (National Summary), but IUI (intrauterine insemination) "is not considered an ART procedure because it does not involve the manipulation of eggs." Elsewhere, I also found a brief summary of infertility treatments.

The original article doesn't explicitly mention IUI, though it does suggest that fertility drugs (a significant factor for IUI stats?) result in many more High Order Multiples (HOM) than IVF. Presumably, such older treatments are less often performed now and Dr. Evans would therefore have fewer patients, but, currently, 75% of Dr. Evans's patients have become pregnant through IVF. Perhaps adding to this percentage is the fact that Dr. Evans has become more willing to reduce from 2 to 1.

From the article: "When he began performing reductions 20 years ago, about 75 percent of his patients had gotten pregnant using fertility drugs alone, which often cause a woman to ovulate many eggs at once, and can result in extremely high-order multiples. Back then, he estimates, about 40 to 45 percent were pregnant with quads or higher; the same percentage were carrying triplets; and 10 percent were twin pregnancies in which one fetus had a serious problem. But things have changed. Now, 75 percent of his patients have gotten pregnant through IVF, a more controlled form of fertility treatment, and the size of the pregnancies has gone down. Now it's 5 to 10 percent very high-order multiples, 20 percent quads, 60 percent triplets, and about 10 to 15 percent twins."

I agree that IVF is better than certain alternatives which are more likely to cause HOMs. I don't really disagree with your post, and I'm not sure what (or whose) previous statements you are specifically addressing or refuting.

Kevin

Anonymous said...

Honestly, I don't trust this reporters information. The 2004 statistics are the latest for the CDC - the same, more recent, information is on the ASRM web site. I have heard her interviewed several times and she has repeatedly misused terminology that any good science reporter would know by the time they are writing a book about the topic at hand.

When you spend time studying a field, you tend to pick up the lingo. I know this from my previous work as a librarian. Reporters are not fact-checked by anyone these days.

Personally, I find it abhorrent that he is reducing any non-high risk twin pregnancies to one fetus. Twins, with proper pre-natal care, are almost always viable. (There are exceptions, where one twin is not viable and puts the other at risk, it is reasonable to reduce, otherwise, no.)

MamasBoy said...

First of all, thanks for your comments. I hope my phrasing doesn't come across as inconsiderate; I'm genuinely interested in hearing what you have to say.

"Honestly, I don't trust this reporters information."

I'm really at a loss to figure out what you don't trust. Everything? You seem to indicate a distrust of her description of selective reduction being done mostly with IVF, though like I said I'm not sure what you specifically object to. What percentage of selective reductions would you say are done for IVF and what percentage are done for IUI? Is this published anywhere?

Also, you state that find the selective reduction of twins to be "abhorrent." I'm curious as to why you say this. Do you think that the fetus has a right to life similar to a newborn? Is there some other standard which you propose that doctors should use to guide their actions? What is that standard?

Lastly, I'm disappointed that you would accuse me so rashly of being evasive about abortion in the case of ectopic pregnancies. I quoted the word "abortion" to not to deny that it is an abortion in the practical sense of the term, but to highlight that such a procedure could *also* be referred to in other terms since there is more that is going on than the simple removal of the fetus from the uterus as in a typical abortion. In the cases I mentioned (e.g., cancer of the uterus and ectopic pregancy), the uterus and/or fallopian tubes are operated on and quite often part of them is removed in order to to correct the pathological condition. This is a distinction worth noting, especially when discussing the ethics of abortion. I suppose some might call pregnancy a pathological condition, but I would differ on that point. There are certain things in life, like pregnancy and eating, that are normal activities of a healthy person, but which can be associated with pathological developments.

MB

purple_kangaroo said...

MB, you brought up an interesting point. You said, "I'll throw out some psychotic situation as an insufficient analogy to try and illustrate my difficulty. If someone handed me a gun and said kill that person sitting down over there or I will kill 100 people, I don't think I would follow through. On the other hand, if train full of 100 people was headed toward a precipace, but I could save them by diverting the train to another track where a kid was tied up, I would divert the train. The kid dying is a byproduct of me trying to save lives. That's a really poor example, but I think it kind of gets at the dilemna of murder as treatment or death as a byproduct of treatment. "

In your first example, what if your choice was between watching 100 people get shot, or stopping the carnage by shooting the gunman. If you had a gun and the ability to use it, but no other way to stop the shooter, would it be moral to use "murder as treatment" in that situation? That seems a more accurate comparative hypothetical situation to me.

Although the child has no evil intent, in the case of something like an ectopic pregnancy or certain other situations, it is in fact the baby itself, indirectly, that is the cause of the risk to others' health. A difficult, but in some ways similar, dilemma is the case of some conjoined twins.

To me, killing an innocent and completely uninvolved bystander as "treatment" is a different situation than killing the person who is actually the cause of the risk to another's life. It's a small distinction, but it seems relevant to me.

I would say that the risk to the life must be severe, and the chance of saving that life by sacrificing another must be great, to make the situation moral. But I do think that it's probably not right to force a mother to sacrifice her life, or take the likelihood of doing so, for a chance of saving her baby's life--especially since most likely both mother and baby would die.

The same with conjoined twins. In a case where both would almost certainly die if they were left together, but one would die and one would have a good chance of living if they were separated, I think as a parent I would likely choose to separate them. It would be a hard, hard choice, though. Agonizing.

It's much easier in the case of something like an ectopic pregnancy, where the baby has a pretty near 100% chance of dying whether the mother receives an abortion or not.

In a case where it was literally a choice between saving the mother's life or the child's life, or between most likely saving one child by taking another's life, it would be a much harder decision. Thankfully, such cases are very rare if they do happen.

MamasBoy said...

PK,

While I admit that my earlier analogy has serious shortcomings, I'm not sure your modification fixes them.

Killing the shooter is killing a person who has intent to kill. It is equivalent to shooting a guy who is about to take a crowbar to a pregnant woman. I don't think a human fetus can be considered to be the shooter in my analogy.

Feel free though, to continue to come up with better analogies. I'd know mine had faults and would appreciate it if you came up with something we both thought was equivalent.

MB

Kevin said...

PK's analogy may be better for cases where a specific fetus is threatening the mother's (or other fetus's) life, while MB's may be better for cases where the number of fetuses threaten one another, and killing some of them, even arbitrarily, might save the rest.

While the life of the mother is at increased risk with multiples, I didn't get the impression that that was the primary factor in most selective reductions.

As I mentioned before, I think the distinction between MB's two analogies seems to be "perceived risk" (the treatment harms) versus "actual risk" (the side-effect harms), since the perpetrator could have staged the train scenario. Is that right, MB? Or am I missing something?

Maybe another analogy is pushing people off of a life raft, so the whole thing doesn't sink... assuming that jumping off the raft yourself is insufficient.

Kevin

purple_kangaroo said...

The life raft seems like a pretty decent comparison to me, I guess, maybe. :)

steviepinhead said...

The "life raft" situation is a classic first-year law school conundrum. I think the "real" examples involved life-boats and British steamships. I'll have to hunt around sometime...

My take on the distinction that MB was drawing was not whether one life directly "threatened" another, but whether some sort of intent to harm was involved.

If I've got that right, then one could construct a kind of spectrum, from sacrificing one entirely innocent life to save another/others, to sacrificing a life that was in some sense actively "threatening" another with harm (though not with any sort of intent), to one where intent was involved.

Kevin said...

Argh, the lawyers beat me to it! :)

Intent does seem to be central, Stevie, though I think negligence should be somewhere in that spectrum -- wherein one acts or refuses to act, knowing the side effects, even if those are not the primary intent.