Dr. Danny Eisenberg
January 18, 2004 GRAND RAPIDS, Michigan (AP) -- A woman pregnant with sextuplets has given birth to the five remaining babies more than a week after delivering the first, a hospital official said Saturday.
With the birth in January of a set of live sextuplets in Grand Rapids, Michigan, it is timely to examine the Jewish view of a common complication of infertility treatment, multiple gestations. Such excitement has not occurred since 1998, when the first known set of live septuplets occurred in the United States. Such multiple gestations are rare, with 6,742 sets of triplets, 506 sets of quadruplets, and 77 sets of quintuplets or higher order pregnancies in 2000.1
Normally, a woman produces one mature egg per month. A common infertility treatment requires a woman to take ovulatory drugs which cause her to hyperovulate, producing many mature eggs at one time. These multiple eggs may be allowed to proceed naturally through the fallopian tubes to be fertilized or they may be extracted and used for in vitro fertilization. In the former case, a multiple pregnancy may occur without any other intervention. In the latter case, a decision must be made as to how many eggs to implant following the in vitro fertilization procedure.
Because of the high cost of treatment and the relatively low success rate of such treatments (which is improving every day), a decision is sometimes made to implant several fertilized eggs. The expectation is that only a few of the eggs will result in a viable pregnancy and that hopefully, at most one or two children will be born.
Therefore, an undesired result of infertility treatment is the situation of a woman pregnant with up to seven fetuses. Women who have multiple gestations are at increased risk for many types of complications, including gestational diabetes, premature delivery, eclampsia (severe high blood pressure and seizures), and birth defects. They are usually forced to spend much of the pregnancy in bed to minimize the risk of complications. The complication rate for twins is higher than for singletons, and the rate of complications only increases as the number of fetuses in the womb increases, with a steep jump with quadruplets.2 Not only does the danger to the mother increase with more fetuses, but also the risk of miscarriage, ending the lives of all of the fetuses increases. As a result, many physicians recommend selectively aborting some of the fetuses to reduce the pregnancy to twins or triplets at most.
The Committee on Ethics of the American College of Obstetrics and Gynecology
Insofar as the intention of selective termination is different from that of other multifetal reductions, its ethical rationale is importantly distinctive. That is, the intention in selective termination is to avoid having a child with a known medical problem, whereas the intention in multifetal reduction is to prevent problems that are secondary to multifetal gestation and premature birth.
רוצח גופיה מנא לן סברא הוא דההוא דאתא לקמיה דרבה ואמר ליה אמר לי מרי דוראי זיל קטליה לפלניא ואי לא קטלינא לך אמר ליה לקטלוך ולא תיקטול מי יימר דדמא דידך סומק טפי דילמא דמא דהוא גברא סומק טפי
The Gemara asks: From where do we derive this halakha with regard to a murderer himself, that one must allow himself to be killed rather than commit murder? The Gemara answers: It is based on logical reasoning that one life is not preferable to another, and therefore there is no need for a verse to teach this halakha. The Gemara relates an incident to demonstrate this: As when a certain person came before Rabba and said to him: The lord of my place, a local official, said to me: Go kill so-and-so, and if not I will kill you, what shall I do? Rabba said to him: It is preferable that he should kill you and you should not kill. Who is to say that your blood is redder than his, that your life is worth more than the one he wants you to kill? Perhaps that man’s blood is redder. This logical reasoning is the basis for the halakha that one may not save his own life by killing another.
ורוצח גופיה מנא לן סברא היא דההוא דאתא לקמיה (דרבא) אמר ליה אמר לי מרי דוראי קטליה לפלניא ואי לא קטילנא לך א"ל נקטלך ולא תקטול מאי חזית דדמא דידך סומק טפי דילמא דמא דההוא גברא סומק טפי
The Gemara asks: And with regard to the murderer himself, from where do we derive this halakha that he should be killed rather than transgress the prohibition against murder? The Gemara answers: It is derived through reason, as it was told: A certain person came before Rava. He said to Rava: The master of the village where I live said to me: Kill so-and-so, and if you do not do so, I will kill you. What should I do? Rava said to him: Let yourself be killed, and you should not kill. Rava reasoned: What did you see to make you think that your blood is redder and more important than his? Perhaps the blood of that man is redder, and he is more important than you. If so, it is logical that one must not kill another person to save himself.
סברא הוא - שלא תדחה נפש חבירו דאיכא תרתי אבוד נשמה ועבירה מפני נפשו דליכא אלא חדא אבוד נשמה והוא לא יעבור דכי אמר רחמנא לעבור על המצות משום וחי בהם משום דיקרה בעיניו נשמה של ישראל והכא גבי רוצח כיון דסוף סוף איכא איבוד נשמה למה יהא מותר לעבור מי יודע שנפשו חביבה ליוצרו יותר מנפש חבירו הלכך דבר המקום לא ניתן לדחות:
The reason why A may not push aside B’s life (to save his own life) is: If A kills B, there will be two negative consequences (“תרתי:(” B’s death and a transgression of an Aveirah (sin). However, if A remains passive, there will be one negative consequence (“חדא :(” A’s death, but he will not transgress an Aveirah. The Torah only permitted us to violate Mitzvot based on the “V’Chai Bahem-dispensation” because a Jewish life is precious to Hashem (more than Mitzvot). However, here, if A kills B, (the “V’Chai Bahem-dispensation” won’t apply for the following reason): Since one Jewish life will be anyway lost in the end, why should it be permitted to transgress the Aveirah? Who says (lit. who knows) that your (A’s) life is more dear to Hashem than your friend B’s life? Therefore, the words of Hashem may not be pushed aside.
אגרות משה יו״ד ח״ב סימן ס ענף ב
דהא כתבתי שהא דאסור להרגו משום דמשמיא קא רדפּי לה, אינו מחמת שאינו בדין רודף כיון שהוא דרך טבעי שלא בכוונת רדיפה, אלא כיון דמשמיא רדפּי לה נחשבו שניהם כרודפים זה את זה מאחר שאי אפשר שיחיו שניהם שלכן אסור מטעם מאי חזית. ואם כן לא שייך זה אלא כשהם רודפים שוים כהא דיצא ראשו שהיא נפש גמור כמו האם. אבל בעובר שעדיין אינו נפש גמור כדחזינן שאין נהרגין עליו, ונמצא שעל היתרון של האם מהעובר שהיא נפש גמור והוא אינו עדיין נפש גמור, הוי רק העובר רודף ואם אינה רודפת. לכן יש להעובר דין רודף מחמת היתרון זה שיש להאם עליו.
Igrot Moshe YD 2:60:2
I have written that (when the Gemara states that) the prohibition to kill him (the ‘partially-emerged fetus’) is due to ”לה רדפי קא משׁמיא‘) “they are pursuing her from Heaven”) it is incorrect to interpret (that the reason) that we do not apply the law of Rodef is because the danger occurred through natural means without (the baby’s) intent. Rather, since it is Heaven that pursues her, it is considered that both parties are as mutual pursuers after each other since (we see that Heaven has declared that) it is impossible for both to live. Consequently, it is forbidden to kill the baby due to “Mai Chazit” (“why do you presume that the baby is any more of a Rodef after his mother than she is Rodefet after the baby?”). However, this applies only when both parties are equal pursuers, as in the case of the ‘partially emerged fetus’ who has the identical full Nefesh (life) status as his mother. However, prior to birth, the ‘non-emerged fetus’ has an incomplete Nefesh status, as we deduce from the fact that one is not liable for capital punishment for killing a fetus. Therefore, regarding the advantage (i.e., the ‘Nefesh -differential’) that the mother has over the fetus – that she is a complete Nefesh while he is not yet a complete Nefesh - only the fetus is a Rodef and his mother is not a Rodefet. Therefore, we apply the law of Rodef to the fetus because of the advantage that the mother has over him.
נשמת אברהם חושן משפט סימן תכה
בשאלה של ששיה אמר לי הגרש"ז אויערבאך זצ"ל שמותר לגרום להפלה חלק מהעוברים כדי להציל האחרים. במקרה אחר באשה עם רביעיה דעת הרופאים שלא תוכל להמשיך עם הריונה עקב האגן הקטן והתיר הגאון זצ"ל שיפילו אחד או שנים מהעוברים לפי הצורך. הסביר לי הגאון זצ"ל שבמקרה של הריון בסיכון גבוה עקב ריבוי עוברים כל אחד מהעוברים יש לו דין של רודף ולכן מותר לרופא להרוג חלק מהם בזריקה בבחירת אותם לפי שיקול רופאי שהריגתם יגרום לסיכוי הקטן ביותר של הפלת כולם. והוא זצ"ל גם הסכים שמותר לעשות זאת אחרי ארבעים יום (מבחינת רפואי הזמן האופטימי לבצע דילול הוא בין תשע לשתים-עשרה שבועות של הריון). ואמר לי הגרי"ש אלישיב שליט"א שכיון שהרופאים אומרים שיש סכנה ברביעיה שתפיל את כולם, מותר לדלל. . מאידך ידוע לי שהגאון שליט"א אסר דילול בשלישיה.
Nishmat Avraham C"M 425
In a sextuplet pregnancy case, the Gaon, Rav Shlomo Zalman Auerbach, ZT”L told me that it was permitted to reduce a portion of fetuses to save the others. In another case where doctors believed that a quadruplet pregnancy would become inviable due to the mother’s narrow pelvis, the Gaon, ZT”L permitted reduction of one or two fetuses, as the situation required. The Gaon, ZT”L explained me that in cases where the pregnancy is at high risk due to multiple fetuses, each of the fetuses has the status of a Rodef and therefore the physicians are permitted to select those fetuses for reduction whose termination will cause the least risk of aborting the entire pregnancy. He also agreed that this is permissible even beyond 40 days, based on the opinion of contemporary physicians that the optimal time for reduction is between 9-12 weeks of gestational age. In a case of a quadruplet pregnancy, the Gaon, Rav Yosef Sholom Elyashiv, ZT”L, told me since the doctors assess that there is danger that all fetuses will be miscarried, it is permitted to reduce. On the other hand, it is known to me that the Gaon (Rav Elyashiv), ZT”L, forbade reducing a triplet pregnancy.
Rav Hershel Schachter (Reference 8) explains that the position of Rav Moshe, i.e., the prohibition of feticide is included under Lo Tirtzach (“thou shall not murder”) is based upon the eventuality that a fetus would become a viable born person (סופו שׁם על .(Therefore, if the physicians state with near certainty that all fetuses will die unless MPR is performed, since the eventuality of a viable born person does not exist, there would be no prohibition of Lo Tirtzach and therefore MPR would be permitted to save the remaining fetuses. According to this explanation, Rav Moshe would not agree with Rav Elyashiv that a mortality risk of greater than 50% would suffice to permit MPR, as Rav Moshe would require a much higher mortality risk to permit MPR.
(כג) סיעה של בני אדם שאמרו להם נכרים תנו לנו א' מכם ונהרגהו ואם לאו הרי אנו הורגין את כולן יהרגו כולן ואל ימסרו להם נפש אחת מישראל אבל אם ייחדוהו להם כגון שיחדו לשבע בן בכרי יתנוהו להם ואל יהרגו א"ר יהודה בד"א בזמן שהוא [מבפנים והן] מבחוץ אבל בזמן שהוא מבפנים והם מבפנים הואיל והוא נהרג והן נהרגין יתנוהו להן ואל יהרגו כולן וכן הוא אומר (שמואל ב כ) ותבא האשה אל כל העם בחכמתה וגו' אמרה להם הואיל והוא נהרג ואתם נהרגין תנוהו להם ואל תהרגו כולכם ר"ש אומר כך אמרה [להם] כל המורד במלכות [בית דוד] חייב מיתה.
(23) A group of [Jews] to whom gentiles say, “Give us one of you and we shall kill him, and if not, behold, we will kill all of them”; they should let themselves be killed and not deliver them one soul from Israel. But if they designated [the person] to them – for example, Sheva ben Bichri – they should give him to them and not let themselves be killed. Rabbi Yehuda said, “When do these words apply? In a case when he is [inside and they are] outside [a fortified city]; but in a case when he is inside and they are inside, since he will be killed and the [other Jews] will be killed, they should give him to them and not let themselves all be killed. And so did it state (II Samuel 20:22), ‘And the woman come to all of the people in her wisdom, etc.’ – she said to them, ‘Since he will be killed and you will be killed, give him to them and do not kill all of you.’” Rabbi Shimon says, “So did she say [to them], ‘Anyone who rebels against the monarchy [of the House of David] is liable to [receive] the death penalty.’”
תלמוד ירושלמי תרומות ח:ד
תָּנֵי סִיעוֹת בְּנֵי אָדָם שֶׁהָיוּ מְהַלְּכִין בַּדֶּרֶך פָּגְעוּ לָהֶן גּוֹיִם וְאָמְרוּ תְּנוּ לָנוּ אֶחָד מִכֶּם וְנַהֲרוֹג אוֹתוֹ וְאִם לָאו הֲרֵי אָנוּ הוֹרְגִים את כּוּלְּכֶם ,"אֲפִילוּ כּוּלָּן נֶהֱרָגִים לֹא יִמְסְרוּ נֶפֶשׁ אַחַת מִיּשְׂרָאֵל. יִיחֲדוּ לָהֶן אֶחָד כְּגוֹן שֶׁבַע בֶּן בִּכְרִי, יִמְסְרוּ אוֹתוֹ וְאַל יֵהָרְגוּ. אָמַר רַבִּי שִׁמְעוֹן בֶּן לָקִישׁ וְהוּא שֶׁיּהֵא חַיָּיב מִיתָה כְּשֶׁבַע בֶּן בִּכְרִי. וְרַבִּי יוֹחָנָן אָמַר אַף עַל פִּי שֶׁאֵינוֹ חַיָּיב מִיתָה כְּשֶׁבַע בֶּן בִּכְרִי.
This is the ruling for groups of people who were traveling and were accosted by non-Jews, who said: “Give us one of you and we will kill him; and if not, we will kill all of you”. Even if all of them will be put to death, they should not hand over even one person of Israel. But if the non-Jews singled out someone, as in the Sheva ben Bichri episode, they should hand him over and not get killed. Rav Shimon ben Lakish said, This is providing he is subject to the death penalty like Sheva ben Bichri was. But Rav Yochanan said, This applies even if he was not deserving of the death penalty like Sheva ben Bichri was.
Rabbi Yitzchak Zilberstein, a prominent contemporary halachic authority, approaches the question in a rather original way. He first suggests that if the pregnancy is not a threat to the mother, then aborting some of the fetuses might not be permitted due to concerns of choosing one life over another. Rabbi Zilberstein then proposes two approaches that would suggest that multifetal reduction might be permissible even if only to save the lives of some of the fetuses.
Rabbi Zilberstein brings an analogy to a case in the Talmud, where a group of people who are attacked and are asked to turn over one member of the group (to be chosen by the group) for execution or all will be killed. While most halachic experts rule that all must die, rather than choosing an innocent party to be killed, Rabbi Zilberstein points out that there are authorities who restrict the prohibition of choosing someone to cases where the chosen victim could theoretically escape. But if it was clear that all would die if one were not turned over, then some authorities allow an innocent person to be chosen by lottery and sacrificed to save the others in the group. If this conclusion applies to already born people with full human status, then certainly it should apply to fetuses who do not yet have the status of being viable. That is, so long as the fetuses are in utero, they do not necessarily fall under the prohibition of not choosing one life over another. Therefore, multifetal reduction should be permitted as an act of life-saving fetal protection and not as an act of fetal destruction.
Rabbi Zilberstein also compares pregnancy reduction to using a tractor to save people trapped in the rubble of a collapsed building. If all will die if nothing is done, then he argues that some scholars would permit the use of the tractor to plow through the rubble. Even if some of the doomed people are killed sooner by the tractor, many people may be saved who would have died. Similarly, since all of the fetuses will likely die, he argues that it is permissible to kill a few prematurely to save the rest.
Rabbi Chaim Dovid Halevi, in the same compilation of halachic articles, takes a more lenient approach. He contends that there is a spectrum of opinions regarding abortion (from very restrictive to allowing abortion for Tay Sachs up to seven months) and that most authorities agree that aborting a non-viable fetus is not murder. He hence he argues that multifetal reduction is permissible if by not performing the reduction, the fetuses will be born prematurely and with severe mental or physical defects. He allows reducing to the point necessary to allow the remaining fetuses to be born healthy.