Decision For or Against MPR in light of Halakhah

The discussion of a woman's right to choose to have an abortion or to carry a fetus to term has been a pressing issue for decades, one that does not appear to be disappearing any time soon. One's position on this matter often plays a heavy role in one's political decisions, and is at times seen as indicative of a person's outlook on morality, religion, and life in general. I would like to focus on a subtopic of the abortion discussion, one that has received intense media coverage lately as a result of the recent birth of octuplets in California. The issue to which I am referring is the question of multi-fetal pregnancy reduction (MPR), a procedure in which the number of fetuses is selectively reduced in hopes of increasing the possibility of a healthy and safe pregnancy. MPR complicates the discussion of abortion because of the additional factors involved. One factor is the consideration of the risks associated with multiple births, both for the mother and for the fetuses. Another is the fact that once a decision is made to reduce, the parents must decide how many fetuses should be left to develop to term. I have been spending time over the last several weeks shadowing an obstetrician who specializes in fertility issues, in vitro fertilization (IVF), and high-risk cases. MPRs make up a significant percentage of the daily schedule of this particular obstetrician. As a result of infertility, many turn to IVF, and, in many cases, more of the implanted embryos develop into fetuses than the parents expected or hoped for. Women may become pregnant with three, four, or, in extreme cases, even more fetuses. The risks that accompany a pregnancy of that nature are elevated for the mother, and the likelihood of any of those fetuses growing normally and developing into healthy children is drastically decreased. As a result, many families, with the guidance of their doctors, choose to reduce the number of fetuses. Often, the decision is made to reduce to twins, but frequently to a singleton as well, on the theory that that is the best way to guarantee a healthy pregnancy for both mother and fetus. As is true in many doctors' offices, the walls of the office I have been spending time in are covered with pictures of healthy babies, born as a result of the work of the doctors in the practice. I have spent some time looking at the pictures; there are many single babies, and almost as many pictures of twins - not surprising in an office that specializes in high-risk cases. Although significantly fewer, there were several pictures of triplets as well. In all of my looking through the pictures, I have found only one picture of quadruplets. Judging from the kippot worn by the boys in the photo, it is obvious that they belong to a religious Jewish family. I was immediately struck by the fact that the only picture of quadruplets was one of apparently religious Jewish children, and that in all likelihood many families, when faced with a quadruplet pregnancy, would have chosen to reduce, to increase the possibility of having healthy children. The decision to reduce is not an easy one for any parent, but for Jewish families who live by Halakhah the decision is even more complicated. There are major halakhic considerations that must be taken into account in the decision to reduce a pregnancy, or, on the flip side, to allow one to continue if there is the possibility of the mother being at risk. I would like to discuss the halakhic issues associated with MPR, and how issues of the health of the mother, the viability of the fetuses, and the best estimation of future outcome all play a role in the decision making. The first factor in the discussion is one that comes up in all issues of abortion - the question of at what point in development a fetus gains the status of a living being. The Gemara in Yevamot 69b states that until forty days of development, a fetus is simply considered fluid and has not yet reached the status of life. However, while this may be true, based on a discussion in Sanhedrin it is apparent that Judaism also believes that, from the moment of conception, potential life has begun and with it some level of the Godliness associated with being human. This is derived in that Gemara from the fact that a non-Jew is liable to the death penalty for the killing of a fetus (while a Jew is not). As a result of this, the fact that a fetus is simply within its first forty days is not reason enough to permit termination. Unlike modern scientific discussions, which relate to pregnancy and fetal viability in terms of trimesters, the next temporal distinction made by the Gemara deals with stages of childbirth. Based on a pasuk in Parashat Mishpatim, Hazal determined that a fetus that is endangering the life of the mother is considered a rodef, someone who, because he is pursuing another to kill him, can be killed before he has the opportunity to do so. The Shulhan Arukh states that if a woman is having a particularly problematic childbirth, it is permissible to kill and dismember the baby to save the mother, clearly indicating that, to whatever extent we consider the baby alive, it does not have the same status as a fully-grown person. It is obvious, in such a case, that while the situation may permit the termination of the pregnancy, it is not because the fetus is deserving of being sentenced to death; rather, every measure is being taken in an attempt to save the mother. However, the Gemara goes on to say that once the majority of the baby has been delivered, it is forbidden to kill the baby to save the mother, since no one can choose one life over another. Apparently, by midway through delivery, a baby acquires the status of a full-fledged human. Further discussion of terminating a fetus comes two pesukim later in Parashat Mishpatim where the Torah discusses repercussions and payment for damaging another person or the property of another. There, the Torah states that if two men are fighting and one of them strikes a pregnant woman and she miscarries, as long as she does not die as well, the damager pays the price set by the husband for the value of the fetus. If the woman dies, however, he faces the death penalty. Again, this discrepancy between the killing of a fetus and the killing of the mother is indicative of the fact that the fetus is not considered to truly be a life, and therefore terminating a pregnancy is not considered murder. Many posekim even believe that a fetus is not considered a full-fledged human being until several days after birth. This may be due to the fact that over the centuries an incredibly high percentage of fetuses, despite appearing healthy at birth, were not known to be viable until they survived beyond the first week or so. All of these considerations are integral to determining whether full abortions or reductions are considered murder, or if their performance would be acceptable as a means to save the mother, who is a full human being. Le-halakhah, the vast majority of posekim believe it is acceptable to perform an abortion to save the life of the mother. Regardless of the possibility for life that the fetus represents, it clearly does not have the same status as the mother, and the mother as a full human being deserves to be saved. With reductions, however, there is another issue at hand - not simply whether reducing to save the mother is permitted, but whether a doctor can choose to reduce one fetus to save another when they are all equal in their viability. They can each be seen as a rodef to the other fetuses, but at the same time they are each the objects of pursuit as the life of each is in danger. Assuming none of the fetuses appears less viable, how should a doctor go about choosing one fetus over another to reduce? Approaches to these questions come from a discussion in the Yerushalmi about a situation where a group of Jews are approached by an enemy demanding that they turn over one member of their group to be killed or else the entire group will be killed. The initial answer given is that the group may not turn anyone over; they must all be killed rather than actively sacrifice a human life. Then, the possibility is raised that if there is a member of the group who, for whatever reason, is not expected to live for much longer, he can be sacrificed to save the group. The opinions range so far as to say that if it is a guarantee that non-compliance with this order will result in the murder of the entire group, they may have a lottery, randomly choosing one member to be sacrificed to save the entire group. The applications to our discussion are clear: can parents choose to reduce some fetuses to save the rest? If not, the likelihood of any of them developing to term is unlikely. It appears from this fact that a reduction should be acceptable. If any of the fetuses appear unhealthy, and therefore unlikely to develop to the point of viability, that should be the fetus reduced, much in the way a sick individual would be selected to save the group. If all of the fetuses appear healthy based on the tests performed, then, as was true in the lottery, the ones to be reduced must be chosen randomly. This generally means the physician will choose the most accessible fetuses, those most likely to allow for a successful procedure. In a recent article in Newsweek magazine, a doctor wrote about his feelings as one of a small number of physicians in this country who perform MPRs. He wrote that reductions will never become commonplace enough that they will be considered acceptable by the total population. At the same time, people must understand that families choosing to have a reduction are not looking to take the lives of their potential children. In fact, just the opposite is true. Families seeking multi-fetal pregnancy reductions understand the beauty and uniqueness of a human life, especially as many of them have had an incredibly hard time conceiving in the first place. They understand that each human life is a reflection of God, and they hope that the decision to undergo an MPR will increase the possibility of them being able to bring a healthy baby into this world. I believe this is the way Halakhah views the situation as well. Judaism believes that each and every potential life is unique and valuable, and everything possible must be done to best guarantee that healthy babies are brought into this world, even if it means procedures such as MPR.

Jessica Gross is a sophomore at SCW majoring in Biochemistry.