Informed Consent and Multifetal Reduction
Informed Consent and Multifetal Reduction
by Bernard W. Freedman, Bioethicist
The New York Times ran a story on October 12, 2009, addressing the issue of multiple pregnancies after In Vitro Fertilization, IVF or intrauterine insemination IUI, and hormone therapy. This article by Stephanie Saul, “Grievous Choice on Risky Path to Parenthood,” follows the patient Amanda Stansel, who, after being told she was carrying six fetuses, decided to reject multifetal reduction and accept the risks for herself and her children.
Following IVF or IUI, multiple pregnancies occur 10 times the rate as it occurs in a natural cycle.
Multifetal reduction is the intentional termination of the life of one or more fetuses for the purpose of allowing the other fetuses to survive. The label of “reduction” is a euphemistic misnomer. Multifetal reductions are a statistically anticipated need to terminate one or more fetuses. A choice is made as to whether or not to terminate, and if so, which fetus or fetuses are selected and on what criteria that selection is made?
Up until the time Mrs. Stansel had an ultrasound neither she nor her husband Thomas were warned of risks of a multiple pregnancy, including multifetal reduction and the unique increased risks due to Mrs. Stansel’s medical condition. The ultrasound showed that she was pregnant with sextuplets.
Many people are desperate to have children and turn to artificial reproductive technologies for help. Unfortunately, many of these patients are not told of the ramifications a multiple pregnancy can have both for the mother and the child. Amanda Stansel was one of these patients who went forward with multiple embryo transfer without her informed consent.
Mothers often suffer significant physical problems which include severe bleeding and possibly death following multifetal reduction. Bereavement groups have been developed to deal with the guilt, fear and anguish over the loss due to ending the life of one or more fetuses or the difficult deaths or severe physical and mental disabilities that may follow for the remaining infants.
For the children, there are substantial increased risks of respiratory distress, intraventricular hemorrhage, bleeding into the brain with potential brain damage, dead bowel (necrotizing enterocolitis), developmental delays, cerebral palsy, and death.
So, what must physicians tell IVF and IUI patients who elect multiple embryo transfer?
Physicians must advise of all significant risks, including those risks that are unique to the patient that may increase the dangers to that patient and or the children who may be conceived. Physicians should not delegate the responsibility of obtaining an informed consent to medical assistants or leave it to written explanations in handout brochures in the office.
The physician must ensure and document that the risks are understood in realistic detail including the eventuality of the need for multiple fetal termination by injecting potassium chloride into the vascular system of the fetus and ending its life. The patient must understand that this risk can be avoided with single embryo transfer.
Physician Liability
Obtaining a real informed consent is difficult to do and it has been shown that most physicians are reluctant to do so. Nevertheless, if these risks are not fully explained and understood the mother cannot actually decide whether or not to proceed. The law prohibits any procedure from going forward without proper consent and it should be understood that liability for the injury, suffering or wrongful death of the mother or children could follow.
