The fetus’ moral status

Although we have not seen arguments directly related to the fetus’ moral status in the MFPR debate, we want to devote some space to this subject because the view on moral status can influence the discussion of the various arguments. Questions regarding the fetus’ moral status and fetal rights have been raised throughout the lengthy debate on abortion, and there is no general consensus on this contested issue. A diversity of values and views, as well as religious and moral perceptions, is presented (Chervenak, McCullough & Wapner 1992: 84). Some philosophers have argued that abortion is morally unacceptable because it robs the fetus of its future, in the same way as one robs a child of his/her future by killing the child (e.g. Marquis 1989: 183). Other philosophers have concluded that although a fetus certainly has the potential to become a human being, it nevertheless has no right to life in the fetal stage – no right, that is, that trumps the woman’s right to protect her health, freedom, and life (e.g. Warren 1973: 43). In addition, there are those who believe that the fetus does not have an independent moral status, but rather a dependent moral status, which is directly linked to the woman’s autonomy (e.g. Chervenak et al. 1992: 84).

In the Norwegian Abortion Act, the woman’s right to self-determination already ranks above the fetus’ right to life. This right to self-determination applies equally to single and multiple pregnancies, as the woman herself may choose to terminate a pregnancy before the end of the twelfth week regardless of how many fetuses she is pregnant with. It is hard to justify that fetuses in a multiple gestation should enjoy a higher (or lower) moral status than the fetus of a singleton gestation. Instead, it is natural to think that fetuses in both single and multiple pregnancies have equal status and rights. It is therefore unnecessary, in our view, to focus on the fetus’ moral status for our discussion. Whatever moral status you choose to confer on a fetus, it should be the same for singletons and fetuses of multiple gestations, and we are unaware of anyone arguing otherwise. 

Arguments against MFPR

In the following, we will look at the arguments that advocate against MFPR and suggest that there is a morally relevant difference between abortion and MFPR. We will discuss the harm argument, the slippery-slope argument, the intention argument³, the grief argument, long-term psychological effects for the woman, and the sorting argument.

The harm argument 

In the debate on MFPR there is one argument in particular that is recurrent, and that we have chosen to call the harm argument (Clemet 2016, Henden 2016b, Nilsen 2016, Rognsvåg and Weiby 2016, Saugstad 2016b). The harm argument asserts that MFPR is morally unacceptable because it involves a risk of harm to the remaining fetuses, and in the Norwegian debate it is mainly the risk of miscarriage that has been in focus. It is widely accepted that those who intend to bring a new person into the world have a great responsibility for the health of that future person, even among those who do not ascribe a moral status to the fetus. In practice, this is expressed as the mother-to-be’s duty not to smoke, drink alcohol, or use other teratogenic drugs during pregnancy (Woollard 2016: 126).

Various views on the fetus’ moral status can lead to a different weighting of the various risks inherent in MFPR, and this might influence how the risk of a miscarriage and loss of a remaining fetus should be weighted. If one deems that the fetus deserves a certain minimum degree of legal protection, this will probably weigh heavily. However, in a real situation where the only risk for the remaining fetus is a possible miscarriage, this argument would not be of particular importance since the woman can decide on such a calculated risk for herself, given that proper information is provided to her (Østborg 2016).

The risk of harm to any remaining fetus that will survive until birth, however, will probably weigh very heavily irrespective of what position one takes on a fetus’ moral status. When Mark Evans, among others, developed MFPR in the early 1980s, most of the interventions were performed in week 9 and 10, but also earlier. In the early 1990s, there was a concern that very early MFPRs (6–7 weeks) might result in an increased risk of malformations of the extremities of the remaining fetuses, and to err on the safe side MFPRs were not performed prior to weeks 12–14 for a period of time. Today, it is regarded as safe to perform MFPRs from 10.5 weeks (Evans, personal correspondence), and the research is relatively clear on MFPRs being beneficial for the remaining fetuses in terms of risk of harm (Evans et al. 2004, Evans & Britt in 2010, Evans et al. 2015). One under-communicated aspect in the [Norwegian] debate is that for multiple pregnancies of more than two fetuses it is routine to consider MFPR, because of the benefits for the remaining fetuses (considering prematurity and all it entails) are indisputable.

 
An estimate that has been prevalent in the [Norwegian] debate is that MFPR carries a procedure-related risk of about 15% for a spontaneous miscarriage of the remaining fetus(es) (Helsedirektoratet 2014, Nilsen 2016). This estimate, however, is one that Torbjørn Moe Eggebø at the National Center for Fetal Medicine (NSFM) presented ahead of a meeting with the Directorate of Health in 2014 and is based on a scenario in which inexperienced Norwegian doctors perform the procedure (Eggebø, personal correspondence). However, no reliable scientific evidence for this figure appears to exist; on the contrary, there is evidence of benefits (Salvesen 2016, Evans 2016). It has also been argued that there are no documented beneficial medical effects from 2-to-1 reductions. Mark Evans has strongly challenged this view in Dagens Medisin (a Norwegian medical newspaper;Evans 2016)⁴.

When discussing the risks associated with MFPR, it is necessary to compare the underlying risk, i.e. the risks associated with multiple pregnancies in itself. For the mother, multiple pregnancies involve risks that include the danger of suffering gestational diabetes, hypertension, and preeclampsia (Santana et al. 2016: 631). For the fetuses of multiple pregnancies, studies have found an increased risk of miscarriage, preterm birth, and low birth weight (Cheong-See et al. 2016: 354). Prematurity and low birth weight, in turn, entails an increased risk of cerebral palsy (McClimmans 2010: 295). Morbidity and mortality increase significantly with the number of fetuses, and it is established that when quadruplets or triplets are reduced to twins, the total risk and the outcomes for both mother and fetus are almost identical to those found in ordinary twin pregnancies (Evans & Britt 2010: 295, Gupta, Fox, Feinberg, Klauser, Rebarber 2015 580e1-5, Stone et al. 2008: 406e1-e4, Evans et al. 2015).

A number of studies to assess the risks associated with MFPR have been carried out. The American professor Mark Evans developed the MFPR procedure that is currently used in Norway (KCl-injection), and he has performed several thousand such interventions. Evans has studied the implications of MFPR ever since the first interventions were performed in the United States in the early 1980s. He has found that a reduction of triplets to twins reduces the risk of miscarriage from 15% to 4%, from triplets to a singleton from 15% to 6% and from twins to a singleton from 8% to 3%. In addition, Evans found that the mean gestational age following a 3–to–1 reduction improves compared to following 3–to–2 reductions, and that the incidence of birth weight below 1500 grams is ten times higher for 3–to–2 reductions compared to 3–to–1 reductions (Evans & Britt 2010). Thus, a reduction of triplets to twins is most beneficial in terms of mitigating the risk of miscarriage, but a reduction of triplets to a singleton would be most beneficial in terms of avoiding harm to the remaining fetus (Evans & Britt 2010). In Norway, we admittedly have very good outcomes for twin pregnancies, meaning that the risk reduction estimates from foreign studies cannot be assumed to be directly applicable to Norwegian conditions. Nevertheless, in a major scientific article from 2014 that summarises 25 years of experience with MFPR and compares the results from 70 research papers, Evans concludes: ‘If one’s definition of success is a healthy mother and healthy family, for both morbidity and mortality, the data show conclusively with multiples, fewer is always better. (Evans, Andriole & Britt 2014: 69). One might infer that Mark Evans, in drawing this conclusion, is normatively recommending that a woman who is pregnant with multiple fetuses should always have an MFPR, but this is not so clear (Evans, Andriole & Britt 2014: 69, Evans, Kaufman, Urban, Britt & Fletcher 2004: 102, Evans et al. 2015). It would seem that the facts allow some to perceive MFPR as an opportunity to improve the health of both the woman and the surviving newborns, while others can argue that MFPR is harmful because it causes the miscarriage of one or more fetuses.

In this context, it is appropriate to remark that if MFPR should not be allowed, a woman pregnant with multiple fetuses can only choose "all or none". Presented with a twin pregnancy, it can be assumed that many who want children, but planned for only one more, may choose to continue the pregnancy rather than choose a full termination of the pregnancy; for example, on the basis that they think the risk of miscarriage for the remaining fetus is unnecessarily high. If, however, a woman who wants children still considers it as an impossibility or too risky to carry all the fetuses to term, one cannot rule out that her choice will fall on an abortion. In this situation, the risk of a miscarriage of the remaining fetus(es) after MFPR is small compared with the 100% certain outcome associated with the abortion of all the fetuses.

Overall, we consider the harm argument inadequate for defending the position that MFPR is morally unacceptable, as there is evidence of neither harm to the remaining fetuses nor for a real increase in the total risk of miscarriage. As we have noted, it is especially the first type of risk – of harm to surviving fetuses – that would be relevant to discriminate between abortion and MFPR.

The grief argument 

Some of the arguments against MFPR have focused on the remaining child’s grief from losing a potential sibling (Hegertun 2016, Kirkeberg and Næsheim 2018, Lund 2018). We choose to call this the grief argument. One can imagine that significant distress will result in a child growing up with the knowledge that he or she might have had a twin. An adult twin has commented that “growing up without my twin sister is completely unimaginable for me”, and further, that “if one does away with the one, the other loses a part of herself” (Henden 2016a). It is understandable that a child who has grown up with a twin cannot imagine anything else. But is this any different for a child who has grown up with a non-twin sibling? Also, in this latter case, it appears difficult to imagine a childhood without the sibling.

Henden, following her original opinion piece, was accused of “sentimentalism” and subsequently wrote a second piece in which she presented four points she felt were problematic about MFPR, none of which revolved around the twin bond, or around losing a part of herself (Henden 2016b). Moreover, many of the published opinions [in the Norwegian debate] that promote the grief argument can be interpreted as appeals to prospective parents of twins, where the emphasis is on the joy of being a parent to twins.

To our knowledge, there are no empirical studies on long-term psychological effects for the remaining child following MFPR. In the absence of empirical data, therefore, and in order to compare the trauma of losing a potential sibling via MFPR versus other abortions, we will consider possible scenarios in which the surviving children learn that their parents have had an MFPR or a conventional abortion performed, respectively⁸.

In one scenario, we have a child A who learned during childhood that his parents had an abortion prior to his conception. It is natural that child A may feel grief over the loss of a potential sibling, but it is more difficult to imagine that child A will feel that he has lost a part of himself or his identity, since that part never existed. Child B has instead learned that the parents had an MFPR. The same will apply here: how can B feel that she has lost something she never had? Some will argue that twins have a stronger connection than other siblings (Skoli 2016, Lund 2018). Nevertheless, it is pure speculation to assume that one will miss this association when one has never experienced it. In particular, there is no evidence that those of us who have lost a twin by spontaneous MFPR – which happens in upwards of 30% of all twin pregnancies (Sampson & Ch. de Crespigny 1992:107-109) – suffer as a result.        

However, there are certain differences between child A and child B. In the case of child A, a phenomenon known in philosophy as the non-identity problem turns up (Parfit 1984). Because the fertilisation process is totally random, both physiologically and socially, we can certainly conclude that child A would not have existed if the parents had not chosen to abort a potentially older sibling. They would simply not have conceived A if they had not had the previous abortion. This means that we could not have had biological siblings older than those we actually have.

However, there are certain differences between child A and child B. In the case of child A, a phenomenon which in philosophy is often referred to as the non-identity problem turns up (Parfit 1984). Because the fertilisation processes are of an extremely random nature, both in terms of physiological and social aspects, we can conclude with certainty that child A had not existed if the parents had not chosen to carry out a given abortion of a potentially older sibling. They would simply not have conceived the particular child A if they had not had the previous abortion. That is, we could, in fact, not have had other biological older siblings than those we actually have.

In another scenario, we can imagine a child C who learns of an abortion the parents had performed after child C’s birth because they did not want more children. Child C will then have “lost” a potential younger sibling. It makes sense that we could have had other younger siblings than we actually have, and therefore this scenario is a closer analogy to the case of MFPR. But even here it is not very relevant to talk about a child having lost a part of himself or his identity, although one can imagine that child C may be left with a feeling of guilt because she exists at the expense of a completely different individual. That is, child C might imagine that if her parents had aborted her, they could have had another child altogether – child D – instead. But since child D is purely hypothetical and does not exist, nor ever did, it makes little sense that such guilt would have a rational basis. For MFPR, one can imagine that this could lead to even greater grief since it is purely coincidental that precisely child C exists, and another was aborted. However, if MPFR had resulted in the other twin being alive and child C was aborted, then child C would not have existed. The majority of the remaining children after an MFPR will probably prefer living with the thought that they exist at the expense of a potential twin rather than not existing at all. Furthermore, this argument can be extended to abortions. In a society with a right to abortions, such as in Norway, anyone born after 1976 can imagine that their parents could have chosen to have an abortion. We find, therefore, that the grief argument has its flaws, but it cannot be rejected categorically. We do not, however, see any reasons why the grief argument should have substantially more relevance for MFPR than for regular abortions, and conclude that the grief argument therefore cannot be used to distinguish between abortion and MFPR.

Long-term psychological effects for the woman

It is natural to discuss whether MFPR might entail psychological consequences for the mother, or more generally, for both parents. There have been numerous studies investigating this issue specifically. In one study, it was reported that a third of the mothers experience symptoms of depression and guilt one year after MFPR. These symptoms, however, were largely absent after two years of follow-up. Compared with mothers of triplets who did not undergo MFPR, the MFPR group reportedly had lower levels of anxiety and depression shortly after the procedure, as well as fewer problems linked to psychological attachment to the children born (Garel et al. 1997: 617). Other studies have shown similar results, with some of the women and parents reporting grief, remorse, and feelings of guilt shortly after they had undergone MPFR, but any long-term psychological effects appear to be mild (McKinney, Downey & Timor-Tritsch 1995: 51, Sentilhes et al. 2008: 295, Schreiner-Engel, Walther, Midnex, Lynch & Berkowitz 1995: 541). It was also found that women who had had a MFPR performed were not subject to elevated risk of developing depression or other mental disorders compared to pregnant women or new mothers who had not had MFPR (McKinney et al. 1995: 51). All of 93% of the women who participated in one of the studies reported that they would make the same decision on MFPR again in the same situation (Schreiner-Engel et al. 1995: 541).

Several studies have examined the long-term psychological effects on women who undergo an abortion. A study from 2000 reported that two years after having completed the procedure, a majority of the participants reported satisfaction with their decision, and that they would make the same decision again. A majority of the women reported that their abortion provided more positive than negative psychological effects, and that they were not depressed. Furthermore, it was found that most of the women who did report adverse psychological effects following the abortion had been depressed earlier in life (Major, Cozzarelli & Cooper 2000: 777). A large quantitative meta-analysis from 2011 examined the relationship between abortion and mental health by collecting data from several studies conducted over a period of fourteen years. It was found that, in comparison with pregnant women who had neither wanted nor chosen to have an abortion, women who did choose to have an abortion had a significantly increased risk of developing mental illness. In this study, it was claimed that 5.5% of the mental illness in this group was directly attributable to the decision to have an abortion (Coleman 2011: 180). When one looks at the more relevant control group – women who wanted an abortion but were not allowed one – the picture is different (Biggs, Upadhyay, McCulloch & Foster, 2017; Stotland & Shrestha 2018).

One might raise the question of whether having an MFPR exerts greater mental stress on the woman or the couple than having an abortion does (Evans et al. 2015), or whether an MFPR represents less mental stress insofar as it increases the likelihood of bringing one or more healthy children into the world. The aforementioned studies tell us that both abortions and MFPRs can be experienced as traumatic and stressful for the woman and for the couple shortly after the procedure. Nevertheless, it is reasonable to assume that a woman who may choose between performing MFPR or aborting all fetuses is best served by the former in terms of long-term psychological effects. It is natural to assume that the positive aspects of giving birth to one or more healthy newborns may partly overshadow the negative effects of the loss of one or more of the fetuses. Therefore, it seems unreasonable to cause more mental stress than necessary by offering complete abortions as the only alternative in a situation where the woman, for various reasons, does not want as many children as the number of fetuses she is pregnant with. Consequently, it is natural to think that the risk of negative psychological long-term effects for the woman cannot justify the assertion that MFPR is less morally acceptable than abortion. On the contrary: women who are denied abortions when they want one do suffer, and women who feel compelled to have an unwanted abortion suffer. We see here that the argument from long-term psychological effects can alternatively be seen as strengthening the moral rationale for MFPR over abortions.

The sorting argument

Some argue that MFPR may not only lead to sorting based on characteristics such as sex and developmental anomalies, but it may also result in a society in which twins will feel discriminated against and generally unwanted (Rognsvåg & Weiby 2016). We call this the sorting argument. For example, as Saugstad asks: ‘[...] what will MFPR on twins do with our view of human relations in general and of twins in particular?’ Moreover, he argues that we need to consider any harm MFPR confers on twins, both those who already exist, and for those who are survivors after such an intervention (Saugstad 2016b). The concern that Saugstad raises can be recognised as a variant of the slippery-slope argument: the acceptance of MFPR will cause a drift towards a generally negative sentiment against multiple births. But is it reasonable to attribute weight to the possibility that twins as a group may feel stigmatised because we have allowed MFPR for twin pregnancies? And is it plausible that we will have a society in which twins [in general] are not wanted?

That MFPR is legally permitted implies neither a moral nor legal obligation to perform the intervention.⁹ The right to abortions has not resulted in children no longer being born in Norway, and the number of abortions in recent years has been fairly stable. In the same way, there is little reason to believe that a majority of women with twin pregnancies will choose to take advantage of MFPR, ultimately leading to a society without twins. Self-determination means that it is up to the woman to decide whether or not to conduct an MFPR until the end of the twelfth week of pregnancy, and that MFPR should be an informed choice based on the woman’s own values ​​and preconditions. To put it bluntly, one might argue that if the twins who already exist have reason to feel discriminated against as a result of legalised MFPR, then so does any person born after 1976.¹⁰

One twin who has participated in the [Norwegian] debate on MFPR argues that if the ultimate consequence of MFPR is a society without twins, it is a sign of more fundamental problems, such as an insufficient level of social benefits for families with twins. He writes that ‘[...] ultimately it is better that the Abortion Act exists in 30 years, than that twins exist.’ (Aastebøl 2016). This can be interpreted as a reverse slippery-slope argument, where Aastebøl fears that prohibiting MFPR in a worst-case scenario may cause abortion legislation to be curtailed or rescinded. It is hard to imagine that the right to abortion will be discontinued after so many years just because a new procedure, which did not exist when the Abortion Act was written, is banned.¹¹ On the other hand, it is precisely a form of curtailing of the current legislation, specifically section 2.3c, which has been on the agenda in debates at government level in autumn 2018. The fear of a more conservative policy and the loss of established reproductive rights may be justified, and there appears to be substantial concurrence between those who now call for abandoning 2.3c, those agitating against MFPR, and those who argue for further restrictions on access to abortions.¹²

There is little to suggest that twins will become extinct in Norway as a result of MFPR, and it is up to the politicians to focus on governing the use of MFPR in the same manner as abortions are governed. Moreover, “twinhood” is not a biological attribute of an individual. The fear of depletion of genetic variation, an important component of the general sorting argument, applies only tangentially to the case of MFPR on twins. Twin pregnancies occur regularly. In contrast to e.g., the case of the extensive use of section 2.3c abortions on fetuses with Huntington’s – which can result in the gene being eradicated – a possible decrease in twin pregnancies will be reversible.¹³

For these reasons, we argue that the sorting argument cannot be used to defend the position that abortion is more morally permissible than MFPR on healthy twins. 

We maintain that these objections are either weak (the grief and the harm arguments), are veiled anti-abortion (pro-life) arguments (the intention argument), or properly belong in the general debate on abortions (long-term psychological effects for the woman), and that the stronger arguments all belong in the section 2.3c debate (the sorting and slippery-slope arguments). Overall, we consider that these arguments against MFPR do not indicate that there is a morally relevant difference between self-determined MFPR on healthy fetuses and other self-determined abortions, and, that these arguments do not provide a compelling defence for a ban on the procedure.

Arguments in favour of MFPR

We will now consider arguments in favour of MFPR. We will consider parental autonomy and discuss why selective, section 2.3c indicated, MFPR is not sufficient (to secure basic reproductive rights).

 

Parental Autonomy

Respect for autonomy, or self-determination, is one of the key principles of medical ethics (Gillon 2003: 307). Through respect for autonomy, we recognise the patients’ right to their own opinions, their own bodies, and their own health, and their right to make choices based on personal values ​​and beliefs. For the decision to have an abortion or an MFPR, it is particularly important that women receive adequate information about treatment options. As a preventive measure, the information must deal with how society can assist her if she chooses to carry the pregnancy to term. This provides the basis for informed consent, which is central to the principle of respect for autonomy (ACOG Committee 2013: 405). When abortion legislation ensures respect for women’s autonomy in their decision whether to have an abortion, why should not the same respect be extended to a woman who desires an MFPR intervention? The woman’s body, health, life situation, and family are affected to an equal extent. If she feels that it would be too great a burden to bring as many children into the world as the number of fetuses she is pregnant with, she should not be forced to terminate the pregnancy by abortion when we are now able to offer her the choice to retain one or more of the fetuses.

The choice of having an MFPR is not an easy decision to make, in the same way that the choice to have an abortion is not. Summing up after 25 years of experience with MFPR, Evans [and Britt] states that ”Fetal reduction of any number is emotionally and morally troubling for couples, even when couples make educated decisions after an extensive consent process” (Evans & Britt 2010: 300–301). To respect the woman and couple’s autonomy does not mean that we impose a decision on them, but rather that we guarantee each woman and couple the freedom to make the choice that is best according to their set of values, religious faith, or personal ethical conviction. We believe that this right and this freedom must be preserved and protected.   

Why selective MFPR is not sufficient

Some will argue that there is a significant moral difference between selective MFPR and MFPR on healthy fetuses. Understandably, the termination of a fetus with severe somatic illness or disorder may be perceived as more morally acceptable than the termination of a healthy fetus. Philosopher Leah McClimmans defends selective MFPR, partly on the basis of the lifeboat principle. She compares a multiple pregnancy with a sinking lifeboat carrying more passengers than its authorised capacity, arguing that it may be acceptable to sacrifice some individuals so that all do not perish. She next questions if the force of this argument is weakened when applied to MFPR on healthy fetuses. She argues that it is reasonable to assume that parents who want nonselective MFPR believe that not reducing the number of fetuses would also cause suffering or injury. McClimmans emphasises that it is problematic to use only medical facts and diagnoses to guide ethical decisions. Empirical facts, she argues, are not ethically normative, since they are based exclusively on biological aspects of health (McClimmans 2010: 295).

It is evident that health is a complex concept which, in addition to the biological aspects, also includes mental health, social aspects, and an individual’s own perception of their quality of life (WHO 1946). It is common to maintain that what constitutes good health, and what constitute a harm, is partly a matter of subjective opinion, even in the face of objective medical facts to the contrary. Therefore, it would be wrong to conclude that the presence of a somatic disorder is synonymous with poor health or that the absence of suffering is synonymous with good health (McClimmans 2010: 295). If a woman, based on her own assessment of her life situation, considers that carrying a multiple pregnancy to term with all the fetuses will lead to overall poorer health for her and/or the children being born, regardless of whether a somatic disorder is present, it appears clear to us that MFPR may be a good option for her, and hence a choice we as a society should respect. Based on this, it is difficult to argue that the woman’s health and life situation are weightier factors in the decision to perform MFPR on anomalous fetuses than when the fetuses are healthy. In our view, the claim that selective MFPRs are morally acceptable, whereas MFPRs on healthy fetuses are not, carries the implication that abortions of healthy fetuses must also be morally unacceptable.

Should MFPR be legal?

We have demonstrated that none of the objections raised appear significantly more valid for MFPR than for ordinary abortions. In addition, we have highlighted the right to self-determination as an equally important argument in favour of MFPR as it is for self-determined abortion. In Norway, the right to self-determined abortions has been guaranteed by legislation for more than 40 years. It was difficult, of course, to predict that our society eventually would have to take a stance on MFPR when the Abortion Act was drafted, and it is easy to understand that permitting new medical procedures that deal with life and death lead to a new heated debate. Based on our discussion, however, we find no evidence for the proposition that a country with legalised abortion should not also allow MFPR on healthy fetuses¹⁴.

MFPR has been performed in the United States since the 1980s, and we have pointed to evidence that the procedure employed in Norway does not cause any significantly increased risk of harm to remaining fetuses compared with the risks associated with carrying a multiple pregnancy to term. It is obvious that the procedure requires appropriate training of the physicians who will perform the procedure, just like for any other medical procedure. We consider it reasonable that a relatively small number of physicians should receive training in MFPRs, and that the procedure should be centralised to a national treatment service (Evans 2016).

Given that Norwegian physicians master the method used for MFPR, we see no reason why this procedure should not be permitted under the same conditions as other self-determined abortions. We have only briefly touched on legislation issues in this article, but it is conceivable that it may be clarifying for some if the Abortion Act was amended to include a separate section explicitly addressing MFPRs.

1 At the time of proofreading of this article, there is an amendment to the Abortion Act out for public consultation which seeks to ban self-determined MFPR (Ministry of Health and Care Services 2019). The very recent debate and events are also illuminated in footnotes 7 and 11. At the time of this translation to English, the Norwegian Abortion Act has been amended. It now, in 2020, asserts that MFPR is a form of abortion and is regulated by the Abortion Act. It also states that MFPR is not available to women by self-determination, and MFPR cannot be performed without the permission from an abortion panel, regardless of the timing of the procedure. The law furthermore places additional restrictions on 2-to-1 reductions, and effectively prohibit these.

² The figures for completed MFPR are valid up to 23 November 2018.

3 The intention argument includes the imperative "If you can manage one, then you should be able to manage two" (NTB 2019).

4 And, more recently, again in Dagsavisen April 2019, Evans calls the Norwegian assessment of MFPR ‘bullshit’. https://www.dagsavisen.no/innenriks/sabler-ned-det-norske-fagmiljoet-1.1468910

5 The Norwegian Abortion Act’s section 2.3c regulates second-trimester abortions on indication of fetal anomaly.

6 Some have nevertheless suggested that fetal reduction itself is a form of sorting, since one fetus ‘is selected’ (Saugstad 2016a). It is a curiosity that the term ‘sort’ etymologically derives from the Latin “sortiri”, meaning ‘to choose by lot’. The connotations of the Norwegian word ‘sort’, however, is in a certain sense the opposite: ‘to organise into categories, grouping according to specific criteria’.

7 ‘If you can manage one, you can manage two’ (NTB 2019). In the proposed amendment to the Abortion Act, addressing MFPR, the intention argument is clearly recognisable in phrases about how triplet pregnancies may be reduced to twins, but not to singletons. (MOH 2019).

⁸ There are probably many children who will never know that their parents have carried out MFPR or an abortion. It is hard to imagine that this could have an impact on the lives of these children, and therefore such cases are not appreciably relevant to the grief argument.

9 Although, in the event of a large number of fetuses, e.g., four or more, it can be argued that reducing the number to two is a moral imperative on a par with not smoking or refraining from using drugs, [given the clear and unequivocal benefits of such reductions.]

¹⁰ We recognise that Norwegians born after 1976 are not a minority in society, but that twins are. It is natural to assume that twins may experience that part of their identity is linked with being twins.

11 We have not argued that there is a necessary relationship between (1) opposing MFPR in healthy fetuses and (2) opposing the right to [selective] abortion on anomalous fetuses (cf. section 2.3c). However, it is an empirical fact that the two major organisations that have spoken out most strongly against MFPR – The Christian Democratic Party and the Human Dignity [Menneskeverd] organisation – also advocate strongly against section 2.3c.

12 We have not argued here that (1) rejecting MFPR of healthy fetuses and (2) rejecting abortion of abnormal fetuses is causally connected (cf section 2.3c). It remains an empirical fact that the two major [Norwegian] organisations that have advocated the banning of MFPR – KrF and Menneskeverd – also advocate against section 2.3c.

13 A phenomenon that also applies to chromosomal abnormalities.

14 The fact that something is permitted does not necessarily mean that it comes with a right attached, and under a priority setting perspective it can, of course, be debatable whether MFPR on healthy twins should be offered (free of charge) on request. There is no doubt that an MFPR is something quite different from a regular abortion and requires a lot more resources and expertise – even if we conclude that the involved ethics are comparable. Besides, we have not discussed how reservation issues come into play, and one can imagine that healthcare professionals might have reservations specifically against participating in MFPRs (just as it is possible to have reservations against participating in abortions today in Norway).

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