Be fruitful and subtract?

by Frances Kissling

Frances Kissling is a visiting scholar at the Center for Bioethics at the University of Pennsylvania where she is writing a book on Ethics and Abortion. A Catholic feminist, she was the president of Catholics for Choice for 25 years.
                                                                                   

“Be fruitful and multiply,” the first commandment God gave to Adam and Eve, is a frequent subject of interpretation by Christians as our understanding of the world and the conditions that face humanity have changed over time.

Modern technology --safe, reliable birth control and safe and legal abortion--has made it possible to multiply judiciously and create new persons thoughtfully. Additionally, those who want to have children but are not ‘fruitful” are now able, through a range of modern and not so modern methods from surrogacy to ART (assisted reproductive technologies), to have children.

Single people, gay couples; almost all can now become parents. But new ethical dilemmas arise daily. RememberOctomom -Nadya Suleman who gave birth to a set of octuplets in January 2009 and conceived through in vitro fertilization from a donor? Suleman became one of the most reviled women in America with popular reaction condemning her as irresponsible. Not only did she have eight kids at once, but also she already had six and was experiencing financial hardship. Professional ethicists and policy makers called for limits on the number of embryos that could be implanted during ART to prevent future extreme multiple births.

This week’s Sunday New York Times Magazine is likely to generate comparable reactions and reflection. “The Two-Minus-One Pregnancy” details the use of selective reduction by women who are pregnant with twins. The Times notes that selective reduction, usually is “performed around week 12 of a pregnancy [and] involves a fatal injection of potassium chloride into the fetal chest. The dead fetus shrivels over time and remains in the womb until delivery.” The procedure has long been used in cases where ART results in multiple fetuses, reducing three or more fetuses to twins. Such procedures were medically indicated to increase the chance of successful full term delivery of healthy babies. The Times piece describes the shift from multiple reduction to requests for selective reduction of twins to singles from women who are carrying twins naturally conceived as well as those conceived through ART.

No doubt the women profiled in the story are going to be judged, probably harshly for their decisions. There is little sympathy or understanding of what pregnancy and child rearing means for women. While small families are the American norm, there is a cultural attraction to the “Eight Is Not Enough” way of thinking with several reality TV shows demonstrating how easy it is to be happy and healthy with a slew of kids. The fact that the women in the Times story feared that twins would be “too much” is likely to be considered wimpy at best; selfish at worst

In the opening story, the Times article details a twin pregnancy that resulted from ART and a middle-aged couple who already had grade school children. Twins, the couple felt, would “soak up” the attention needed by the existing children.

But more complicated factors played into and perhaps sealed the mother Jenny’s decision. She notes, “If I had conceived these twins naturally, I wouldn’t have reduced this pregnancy, because you feel like if there’s a natural order, then you don’t want to disturb it. But we created this child in such an artificial manner - in a test tube, choosing an egg donor, having the embryo placed in me - and somehow, making a decision about how many to carry seemed to be just another choice. The pregnancy was all so consumerish to begin with, and this became yet another thing we could control.”

These are big ethical questions - a “natural order” one would not challenge ( yet many naturally-conceived pregnancies are aborted); reproduction reduced to the exercise of consumer choice including the ability to extend your reproductive years and even the definition of infertility itself. Jenny, after all, had children when she was younger but for unexplained reasons wanted more after menopause; so much so that she underwent multiple ART interventions over six years before becoming pregnant this time. The drive to have or not be pregnant and to mother is incredibly strong. And finally, that very ugly word - control. Control over fertility. Control over sexuality. Control. Is control over reproduction a virtue or a vice? And in either case are there limits and boundaries?

For most of human history our control over reproduction and even the survival of the children we created was limited. If we chose to have sex - and most humans did - multiplication was inevitable.

When the personal or social pressures of reproduction became too much, infants and children were deliberately drowned or left in the woods, on a mountain ledge to die. Even without intention, significant numbers of children died simply because there were too many of them in a family to be sustained or their mothers died in bearing them. Most women accepted the unrelenting cycle of pregnancy, childbirth, lactation, pregnancy, ad infinitum that governed their reproductive lives, although historical narratives are filled with the fear pregnancy and childbirth held for women. Futile efforts to figure out how to prevent pregnancy and dangerous efforts to abort some of the pregnancies they failed to prevent are part of the narrative of women’s lives. Dead women were a tragic routine result of “multiplying.” Men simply took another wife. Women were urged by church and state to keep multiplying.

When advocates of reproductive choice confront the ethical dilemmas that selective reduction of twin pregnancies raise, they are likely to retreat to the mantra of choice.

After all, if it is moral to decide for the abortion of one fetus or many for whatever reason a woman considers adequate, then why are we troubled, if we are, by deciding to end the life of one of two fetuses?

But many supporters of legal abortion do grapple with the ethical dimensions of reproduction. That which is legal -and should be legal - may not be ethical. Every decision a woman makes is not ipso facto the best decision - or necessarily a decision that should be lifted up as in the common good. The Times story creates a special dilemma for feminists. We are loath to analyze the decisions individual women make. We fear stigmatizing both the individual woman and all others who might consider making or who have made similar decisions. And yet, most ethical inquiry arises from personal narratives. We learn from our own difficult dilemmas and the experiences of others.

As I read the stories of the Times women, I struggled with my desire to embrace both respect for the value of even early human life and the right or women and men to decide when and how to form families and to have - or not have - children. Neither of those two values is absolute. The women, men and couples in the Times story are all part of the middle class or above, are all well educated and thoughtful people. Their decision-making process after conceiving twins involved serious consideration of the effect having twins would have on them, on the twins if born, and on existing children. Those who conceived through assisted technologies had gone through the usual hell of such processes, many attempts, failures, miscarriages, etc.

Yet, one question never seemed to have crossed their minds. It is a well-known fact that ART results in multiple pregnancies. Did they consider what they’d do if they had a multiple pregnancy as a result of ART? And, is the desire for a child - a child you will no doubt raise well and with love - a high enough good to justify taking the life of another fetus in pursuit of that goal? Are there times when the only ethical thing to do is not get pregnant?

Perhaps no one can or should make that decision for another. It is indeed an awesome decision women make no matter how they conceived a child. It is why most Americans do not want abortion to be illegal. But most Americans think abortion is a serious decision and requires moral justification and reflection. What seems missing is an equal concern about the morality of having children. The number of women who will face the awesome decision about whether to abort one of two fetuses as a result of ART will be small but we will accord it disproportionate attention to the attention we pay to the decision women and men make every day about whether or not to get pregnant and have a baby. The most urgent ethical questions we face are not about abortion. They are about our personal and social responsibility to bring children into the world that have a chance to lead a meaningful life, reasonably free of suffering. Not only should parents be fruitful; their children should have an opportunity for a rich and fertile life.

FRANCES KISSLING