The XX Factor

Selective Reduction After IVF and the Morality of Choice

Maybe it’s the story that got me. Amanda , a few weeks ago, in response to a small flurry about women having post-IVF abortions, you wrote that Dr. George Tiller’s motto was “Trust women.” I thought his, and yours, was a brilliant response to what was clearly a trumped-up outrage over the rare actions of a few women who’d badly wanted a baby and, for nearly always explicable and even justifiable reasons, had to choose not to have one.

“Explicable and justifiable,” though, aren’t usually words I use with respect to my pro-choice stance. I am a choice absolutist; if you were to walk up to me and announce that you had had an abortion because the prospective baby’s birth interfered with your plans to attend a Jonas Brothers concert, I would judge you (both for your action and for your taste in music) but I would not question your legal rights. (The finer points of my thoughts on viability, parental consent, and such aren’t particularly relevant to this post.) But when I read Bettina Paige’s piece ” The Choice ” in the August issue of Elle , I was surprised by how badly I wanted it to turn out differently. Paige has one son; she wanted another child, and her husband agreed, but both felt they could not handle what their IVF procedure dished up for them: twins. After weeks of thought, after an honest assessment of what she was doing, and after (you can’t help but feel, in reading her words) significant pressure from a husband dubious about even the second child, Paige chose to have a doctor “selectively reduce” her pregnancy from twins to a single baby, learning in the process that although there was some medical support for the decision, there is generally considered to be “no medical rationale” for a two-to-one reduction, and also that she was carrying both a boy and a girl.

Paige chose to carry only the girl to term, and she also chose to write about the choice she made, fully and with little concern about what was “explicable” or “justifiable.” There would be financial difficulties. She and her husband would be overwhelmed, the “fragile equilibrium” of their marriage and family at risk. “I know it sounds selfish,” she wrote, “but I wanted to protect the well-being of the people already in my life-my son, my husband, and, yes, myself.”

What Paige did wasn’t technically an abortion, which is the ending of a pregnancy and the emptying of a uterus, says Dr. Mark Evans, who pioneered selective reductions. He defends the practice of reducing twins to a single child on a slippery slope. “After all, he said, if it’s okay to reduce from one to none – that is, if you support abortion rights – then two to one should be okay, too,” wrote Liza Mundy for the Washington Post magazine. Bioethically, it’s the same question.

But is it? Ethics, by definition, change with circumstance: It’s OK to steal to feed a starving baby, but not to gratify your craving for Jonas Brothers tickets. Trust women, Dr. Tiller said. I do. I still want no one else to stand between Paige and her choice: no requirement of danger to the mother, no outside judgment of the circumstances that led to the pregnancy. But I wonder if, as we as a society make the determination that abortion should be safe and legal and as we welcome, as Lauren did after Monday’s Mad Men episode on which Joan revealed that she’d had two abortions, the realistic portrayal of abortion in our fictional dramas, we’re not making it too easy to walk down a dubious road. Should you have to muster the “energy, the patience and the fortitude to juggle two infants in addition to [your] son?” No. But having taken the action to create those two potential infants, I think your moral and ethical obligations toward even their hypothetical lives should loom larger than your similarly hypothetical fears for your own short-term well-being.

From the outside, I can see that the “reduction” of one twin was Paige’s way of trying to take back what she saw as her initial act of irresponsibility: accepting the risk of a multiple pregnancy she (and her husband) didn’t want. No matter what she did, she was going to regret something. I suspect she put too much weight on the trials of infancy and toddlerhood in making her choice, and while I respect it, and I particularly admire her willingness to share it (and expose it to my judgmental gaze), I don’t envy her the moments in her future when she looks at her daughter, and can’t avoid thoughts of her unborn son.

I also think she was wrong.

Amanda, you argued that women who conceive through IVF shouldn’t have to give up any portion of their bodily autonomy, and I agree. No woman should be held to a different legal standard. But when it comes to terminating a fetus for reasons that are more related to choice and circumstance than real, “justifiable and explicable” exigencies, I’d hope women would hold themselves to a higher standard. I think Paige failed. Abortion (or, as here, ending the life of a fetus before viability) should always be legal. We need to continue the discussion of when it’s ethical. If I’d been in Paige’s shoes (and her story of how she made her choice makes it all too easy to imagine one’s self there), I think I’d have taken a different view of what it meant to be a custodian of Dr. Tiller’s trust.

Photograph of vigil for George Tiller by Tim Pierce.