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Selective Reduction: "A Soft Cover for Hard Choices" or Another Name for Abortion?

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Abstract

Selective reduction and abortion both involve the termination of fetal life, but they are classified by different designations to underscore the notion that they are regarded as fundamentally different medical procedures: the two are performed using distinct techniques by different types of physicians, upon women under very different circumstances, in order to further dramatically different objectives. Hence, the two procedures appear to call for a distinct moral calculus, and they have traditionally evoked contradictory reactions from society. This essay posits that despite their different appellations, selective reduction and abortion are essentially equivalent. © 2015 American Society of Law, Medicine & Ethics, Inc.

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... Radhika Rao (2015) contends that how females with multifetal pregnancies resolve the predicament of whether to consider fetal reduction depends on how they 'frame' it: do they frame it in medical terms or in moral terms (see also Britt and Evans, 2007). Medical frames, a la realist position in risk assessment (Lupton, 1999b), focus on health outcomes and risk to the mother and fetus(es) and are driven by a desire to minimize medical risks (Britt and Evans, 2007;Rao, 2015). ...
... Radhika Rao (2015) contends that how females with multifetal pregnancies resolve the predicament of whether to consider fetal reduction depends on how they 'frame' it: do they frame it in medical terms or in moral terms (see also Britt and Evans, 2007). Medical frames, a la realist position in risk assessment (Lupton, 1999b), focus on health outcomes and risk to the mother and fetus(es) and are driven by a desire to minimize medical risks (Britt and Evans, 2007;Rao, 2015). However, medical frames do not always operate autonomously, but work parallelly with an emphasis on concomitant moral frames, emphasizing constructionist position in risk assessment (Lupton, 1999b),e.g., driven by moral precepts about abortion and life, often tied to religious and cultural values (Britt and Evans, 2007;Rao, 2015), and the culturally idealized image of a normative mother/parent. ...
... Medical frames, a la realist position in risk assessment (Lupton, 1999b), focus on health outcomes and risk to the mother and fetus(es) and are driven by a desire to minimize medical risks (Britt and Evans, 2007;Rao, 2015). However, medical frames do not always operate autonomously, but work parallelly with an emphasis on concomitant moral frames, emphasizing constructionist position in risk assessment (Lupton, 1999b),e.g., driven by moral precepts about abortion and life, often tied to religious and cultural values (Britt and Evans, 2007;Rao, 2015), and the culturally idealized image of a normative mother/parent. Risk surveillance during pregnancy, then, blurs the boundaries between medical and moral categories; creating an overlap of realist and constructionist risk positions in which one must take precedence over the other depending on the framework. ...
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Today, across all aspects of societal living, risk assessment is an ever-present exercise. Pervasiveness of technology in the everyday life has caused the world of ‘risk’ to change tremendously, and this is particularly true for childbearing females. The social construction of pregnancy and childbirth as, arguably, medical events that necessitate medical intervention – ever more so for multifetal pregnancies – makes it almost impossible to avoid the notions of risk that surround the events. Drawing on semi-structured interviews with 41 mothers of twins or triplets, we investigate how understandings of risk, combined with the ideology of good motherhood and information provided by physicians impact perceptions of fetal reduction or termination. We have discussed and theorized empirical findings within the framework of risk, discourses of the responsibilization of females, and the potential ‘sacred child’ in a context where selective reduction becomes a potentiality.
... • Selective reduction: In multifetal pregnancies, the purpose of a selective reduction is to improve the viability of a fetus and produce a live birth (Rao, 2015). ...
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The version of California Senate Bill (SB) 245 analyzed by CHBRP would prohibit cost sharing for all abortion services, including follow-up services such as management of side effects and counseling. It also prohibits health plans and policies from imposing any restrictions or delays on abortion services, including prior authorization, and prohibits annual or lifetime limits on any covered abortion services.
... 3,4,5,6,7 However, it has been argued that the practices of abortion and fetal reduction are so closely related that their ethical bearings should not be analysed in strict isolation from each other. 8 While reduction of multiple pregnancies to twin or singleton pregnancies is an established and widely acceptable option, 9 reduction of twin pregnancy to singleton has been comparatively rare. However, reducing twin pregnancy to singleton has become more common in recent years 10 , and is sometimes done for social reasons 11 rather than health. ...
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In her article, “Selective Reduction: ‘A Soft Cover for Hard Choices’ or Another Name for Abortion?,” Radhika Rao explores the dense thicket of contradictions and conflicts related to abortion and selective reduction. Selective reduction is one name for a procedure performed to terminate one or more fetuses in a multi-fetal pregnancy in order to increase the chances that the other fetuses and the pregnant woman will emerge from the pregnancy healthy. Though Rao, in keeping with some authorities, uses the terminology selective reduction in her piece, others prefer the term multi- fetal pregnancy reduction (MFPR) as more reflective of the procedure’s goals and practice. Competing monikers for the same procedure speaks to the importance of naming when discussing the termination of fetal life. It is also a sign of the array of legal, ethical, and medical conundrums surrounding practices that end or alter the course of a pregnancy.
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Assisted reproductive technologies and abortion prompt serious questions about how we should understand the complex relationship between money, markets, choice, and the care relationship. This essay defines "patient" and "consumer," and then describes how they are less important than their attributes. Then it describes theories of commodification and consumption in reproductive contexts and their consequences, from compliance and coercion to resistance and creativity. It also examines whether ART and abortion are "markets." Finally, this essay explores how the attributes which comprise the patient/consumer roles can be incorporated into health care reform, and the implications of health care reform models on ART and abortion. © 2015 American Society of Law, Medicine & Ethics, Inc.
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This article is an initial attempt to compare the pre-abortion disclosure mandates that have proliferated in the two decades since the Court decided Planned Parenthood v. Casey with laws that, in the context of assisted reproduction and reproductive health, require specific disclosures beyond a state's baseline informed consent requirements. While some scholars have characterized pre-abortion disclosure laws as sui generis, they share some important common features with disclosure mandates in the context of oocyte donation and other reproductive health procedures. This article suggests that in critiquing pre-abortion disclosure mandates, scholars and advocates should be careful to differentiate the use of disclosure laws in general from uses where the government interest conveys a moral preference against a particular procedure. © 2015 American Society of Law, Medicine & Ethics, Inc.
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When the number of fetuses in multifetal pregnancies is reduced in the first trimester, the gender and karyotypic status of individual fetuses are rarely, if ever known. In these cases, the only basis for choosing to terminate a particular fetus is the physical location of its sac. The term "selective reduction" is therefore inaccurate, and may be psychologically damaging because it implies that specific fetuses have been targeted. We believe that this procedure should be referred to as multifetal pregnancy reduction.
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Assisted reproductive technologies have aided thousands of couples, but complications have resulted in multifetal pregnancies creating a bitter irony for infertility patients. In an effort to increase the rate of intact survival, we have successfully performed transabdominal first-trimester selective termination procedures on 22 pregnancies including one octuplet, five quintuplet, twelve quadruplet, and four triplet gestations. There have been eight sets of twins, and two singletons delivered, seven twin pregnancies are ongoing, and one early and four late losses of pregnancies. With experience we now counsel as to a high likelihood of a technically successful procedure, but we still have concerns for late losses. We have tried to balance the arguments about the direct harms of performing selective termination and the obstetric risks of not performing selective termination. We believe that selective termination should not be considered a "social" procedure. Our data do not yet make clear whether one, two, or three is the optimal number of embryos to leave. Therefore, on the basis of both current obstetric risk factors and ethical reasoning we will continue to support our protocol of optimally leaving twins.
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The induction of grand multiple gestations is a known complication of infertility treatments. The obstetric outcome in such cases has been very poor. We have evaluated, counseled, and performed first-trimester selective terminations for four patients, all treated with human menopausal gonadotropin, one with octuplets and three with quadruplets. In all cases, the gestations were reduced to twins. In two of the four cases, the pregnancy continued to near term without problem and resulted in the delivery of healthy twins. In the third case, pregnancy continued without problems for eight weeks, at which time renal agenesis was identified in one of the twins. In the fourth case, preterm labor five weeks later could not be stopped. Significant ethical issues must be addressed. We argue that selective termination in appropriate circumstances (eg, when the ability to carry the pregnancy to viability is very small) is ethically justified because it meets the criterion of least harm and most potential good.
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Selective reduction of multiple pregnancy is a medical procedure used during the first trimester to reduce a multifetal pregnancy to produce a twin or singleton birth. The technique is used increasingly to manage multiple pregnancies that result from fertility treatment, including ovulation induction and IVF. This article explores the medical, legal, and ethical aspect of selective reduction, acknowledging throughout the relationship between this treatment for multifetal pregnancy and abortion. Following an update of the medical literature in Part I, Part II focuses on the intent of the parties participating in selective reduction and abortion. A woman undergoing a "traditional" abortion intends that her entire pregnancy will be terminated: that following successful completion of the procedure she will no longer be pregnant. In contrast, a woman undergoing selective reduction intends that her pregnancy will not be terminated, but rather will be enhanced by creating a better environment for her fetus(es) to develop. The difference in intent so separates these two procedures as to render them wholly distinguishable. This distinction should be maintained in the policy-making and political arenas that swirl around the abortion issue. To allow selective reduction to be swallowed up in the abortion debate would be to bury it in the political process much the way other seemingly abortion-related technologies have been buried.Part III of this Article looks at the ethical and moral dilemmas raised by selective reduction. At issue is a basic question pondered over time by moral philosophers and others: Is it ever right to do harm to one just to benefit another. American jurisprudence has often prided itself on protecting the individual from being invaded and hurt by another, reasoning that in a free society, every individual has a right to bodily security. This principle comes sharply into focus when one person asks another to submit to an intrusion of extraction of her body for the sake of the other. Generally, our jurisprudence has denied requests from those in need of rescue, in the form of medical treatment or otherwise, from gaining forced access into another's bodily integrity. Do our hard-wrought concepts on jurisprudence, including the mandate against forced rescue and the duty to do no harm to others, make us bristle at the thought of selective reduction. While these areas of the law serve as relevant analogies, in the end selective reduction must be viewed as the unique scenario that it is -- a lifeboat in the womb in which some must die for the others to live.
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In this Article, Professor Radhika Rao sketches out the parameters of the constitutional right of privacy and applies the right to "new" reproductive technologies, such as artificial insemination, in vitro fertilization, and surrogacy. The thesis of the Article is that privacy - currently miscast as an individual right - must be reconceived as a relational right in order to capture its social dimension. By attaching the right of privacy to entire relationships rather than to isolated individuals, Professor Rao both explains existing jurisprudence and offers a fresh mode of analysis to resolve some seemingly intractable problems posed by assisted reproduction.
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How people make decisions regarding medical technologies and procedures are affected by how they 'frame' those decisions. Medical frames are characterized by a reliance on statistics regarding outcomes and risk to mother and surviving embryos, emphasize the influence of medical authorities, and are driven by a desire to minimize medical risks. Moral frames, on the other hand, are driven more by a desire to minimize the disruption to antiabortion and antireduction moral precepts, and weight heavily the advice of religious leaders. These frames contest with one another. Our objective is to examine the biographical determinants of frame dominance in this contest as it applies to multigestation pregnancies where selective reduction is being considered as a pregnancy-management strategy. For a sample of 55 multigestation women considering multifetal reduction as a pregnancy-management strategy, we develop a distinction between medical and moral frames. Semistructured interviews generated qualitative data that were independently coded by two researchers. These variables were then analyzed using dummy variable regression analysis. Conceptualizing these frames as anchoring opposite ends of a continuum, we show that 40% of the variance in frame dominance can be accounted for by three factors: how involved patients are in religious institutions that have antiabortion norms, whether they have medico-scientific careers, and how pro-reduction their advice has been from fertility specialists and obstetricians prior to coming to the clinic. The implication of these results for practice include recognizing the wide variation in patient's perceptions of their situations and how these perceptual frames alter how women confront risk-benefit statistics and being flexible in one's approach to counseling patients. This approach can further serve as a model for similar reproductive-health dilemmas.
Article
In the past, our group took the position that we would not provide multifetal pregnancy reduction to a singleton regardless of starting number except for serious maternal medical indications or as a selective termination for diagnosed fetal anomalies. With evidence of increased safety and more women (many aged 40 years or more) asking for counseling about reduction to a singleton, we reviewed our prior reasoning. We compared outcomes of 52 first-trimester twin-to-singleton for multifetal pregnancy reduction cases performed by a single operator to twin and singleton data from recent national register studies. Twin-to-singleton reductions represent less than 3% of all cases. Forty of 52 patients were aged 35 years or more, 19 were aged more than 40 years, and 2 were aged more than 50 years (age range 32-54 years). Since 1999, 23 of 28 had chorionic villus sampling before multifetal pregnancy reduction. Fifty-one of 52 reached viability with mean gestational age at delivery of 37.2 weeks. One of 52 patients miscarried (1.9%). Compared with multiple sources of data for twins, the loss rate is lower in twins reduced to a singleton. Until recently, multifetal pregnancy reductions to a singleton were rare. Physicians were concerned about the unknown risks of multifetal pregnancy reduction in this situation. They also had moral doubts about the justification to go "below twins." However, physicians know that spontaneous twin pregnancy losses average 8-10%. Also, with experience, multifetal pregnancy reduction has become very safe in our hands. Our data suggest that the likelihood of taking home a baby is higher after reduction than remaining with twins. We propose that twin-to-singleton reductions might be considered with appropriate constraints and safeguards.
What Is the Difference between Selective Reduction and Abortion?” Yahoo! Health, available at (last visited
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unpublished personal interviews, manuscript on file with author (suggesting that a significant fraction of women interviewed who considered selective reduction regard the procedure as fundamentally different from abortion)
  • See Madeira
Equal Liberty, supra note 43 (arguing that “[l]ines drawn based upon the status of the persons involved would likely be unconstitutional, whereas lines drawn to differentiate between different acts would likely be constitutional
  • See Rao