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RS 414
Casuistry Paper
The Case of Transfused Twins: Must One Die to Ensure the Other Lives?
The case that I will be exploring is a hypothetical one, but the relevant factual information is
based on data taken from an article published by Urig, Simpson, Elliot, and Clewell (1988):
In this case, 28-year-old Amanda Jenkins is 3 months pregnant with identical twin boys. The
twins are monochorionic, which means that they share a placenta and therefore the same
maternal circulation portal. At her 12-week appointment, an ultrasound reveals that
Amanda’s twins are afflicted with severe twin-twin transfusion syndrome, a rare but serious
condition in which an abnormal growth of placental blood vessels connect the circulatory
systems of the twins. As a result of this connection, one fetus (the recipient) receives a
disproportionate majority of the circulating blood supply while the other fetus (the donor) is
typically left with too little blood to adequately support its developing organ system. The
doctor tells Amanda that twins suffering from this particular form of twin-twin transfusion
have a nearly 100% mortality rate without intervention, and after hearing the news, Amanda
decides to undergo amnioreduction as well as a placental vessel puncture. Both procedures
have proven to be about 60% effective in correcting the fatal syndrome, but a second
ultrasound taken at 22 weeks gestation shows that the fetuses did not respond to the
treatment. At this point, the syndrome has progressed far enough that there is less than a 2%
chance the donor baby will make it to term, and as a result, the risk posed to the recipient
twin is great. In order to ensure the recipient twin’s survival, the doctor recommends
immediately cauterizing the connections between the fetal circulatory systems as a means of
preventing both infection and blood clots being passed from the donor twin to the recipient.
Twin-twin transfusion syndrome is a progressive disorder, and thus without taking
immediate and appropriate action, there is a 94% chance both twins will die in utero.
Without the cauterization procedure, even if one of the twins survived, he would surely have
extensive brain damage, especially if it was the donor twin. But if the circulatory connection
is cauterized before infection sets in, the recipient baby will not only survive, but will escape
brain damage as well. However, the cauterization procedure is essentially an abortive
measure as it would mean cutting off the donor twin’s blood supply and shunting the blood
directly from the mother to the recipient. Based on these facts, should Amanda consent to
the procedure?
The moral questions raised in this case are inarguably difficult ones, and thus using casuistry as a
means of coming to a viable solution may be helpful. The four steps of casuistry are outlined below,
and will be appropriately applied to this case.
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Step 1: Identify Paradigm Cases and Justify Choices
For this case study, I believe that the careful use of two paradigms will be sufficient. The first
paradigm case concerns a pregnant woman who discovers that she is experiencing an ectopic
pregnancy. The embryo has implanted itself in the fallopian tube rather than in the uterus, and as a
result the woman is experiencing hemorrhaging. The doctor tells her that she and the baby face a
nearly 100% morbidity rate if the pregnancy is allowed to continue, and thus to stop the bleeding, the
woman voluntarily elects to remove the affected portion of her fallopian tube, thereby terminating
the pregnancy (Gilbert 319 – 320). This case is morally relevant to Amanda’s because it too concerns
the voluntary abortion of a potentially viable fetus. A second relevant factor is that in both cases, the
life of another is put at risk if the fetus is question is allowed to come to term.
The second paradigm case that I feel is morally relevant concerns a couple who discover they
naturally conceived fraternal twins, one boy and one girl. However, the parents only intended on
having one more child, and they are not financially able to support two more babies. Thus, since the
couple already has three girls at home, they choose to selectively abort the female embryo and keep
the male one. This paradigm case is morally relevant to Amanda’s because again, both involve the
voluntary abortion of a potentially viable fetus. More importantly, however, both cases are similar
because they involve the selective reduction of only one embryo in a pregnancy with twins.
Step 2: Identify the Morally Decisive Features of the Paradigm Cases
Though it is a complicated situation from a Catholic perspective, the case study in which the
woman is experiencing an ectopic pregnancy is the “right” example, and it can be considered morally
correct for several reasons. According to the Ethical and Religious Directives, “abortion is never
permitted” and “in the case of extrauterine pregnancy, no intervention is morally licit which
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constitutes a direct abortion (pgs. 22 - 23), and these statements make it seem as though this woman’s
abortion was morally reprehensible. However, it is important to note that when choosing to abort
the child, the woman was already experiencing severe hemorrhaging and that both she and the child
faced certain death if the pregnancy were allowed to continue. Thus, it can be assumed that the
woman did not elect to directly abort the child solely based on the fact it was an ectopic pregnancy;
rather, she chose to indirectly abort the child based on the fact that the only way to stop the
hemorrhaging was to remove the affected portion of her fallopian tube. That the woman indirectly
aborted the child to save her own life renders her actions morally permissible, for as the ERD’s state,
“operations, treatments, and medications that have as their direct purpose the cure of a
proportionately serious pathological condition of a pregnant woman are permitted when they cannot
be safely postponed until the unborn child is viable, even if they will result in the death of the
unborn child” (pg. 23).
The second paradigm case involving the couple who selectively aborts one of their twins is
the “wrong” example, and it is considered morally reprehensible based on the simple fact that
“abortion is never permitted” (pg. 23). In this case, the abortion is obviously a direct one; there are
no external circumstances that render the abortion an indirect or even necessary procedure.
Additionally, the reasons for having the direct abortion are selfish ones. The fact that a couple would
rather have a boy than another girl is by no means a justification for the abortive act, and this
paradigm case can thus be unequivocally classified as the “wrong” example.
Step 3: Identify the Relevant Analogies/Disanalogies and the Unique Features of the Case at Hand
Beginning with the first paradigm case concerning the ectopic pregnancy, several moral
features are shared with the case of Amanda’s transfused twins. First, the two cases are analogous in
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that by allowing the fetus to come to term, a life is put at significant risk. The difference is that in the
case of the ectopic pregnancy, the life at risk is that of the mother, and in Amanda’s case, the life at
risk is that of the recipient twin. A second analogy is that both cases involve the medical necessity of
an indirect abortion to save a life. The method of indirect abortion is dissimilar between the cases (in
the case of the ectopic pregnancy, the fetus would have to be removed with the hemorrhagic portion
of the fallopian tube and in Amanda’s case, the circulatory connection would have to be cauterized),
but the intent to save a life is the same. Because the intent in both cases is the same, and because
both result in an indirect abortion, the two cases are also analogous in that they share the
applicability of the principle of double effect.
According to William Mattison, the principle of double effect is a method of determining the
moral justification of an action that produces two outcomes, one good and one bad. To achieve moral
justification, the action must meet three conditions: “1. The intention must be good, 2. The bad effect
cannot be the means to the good effect, and 3. Proportionality: The good gained must outweigh the
evil effect” (Mattison 172). Indeed, both Amanda’s case and the case with the ectopic pregnancy
meet these conditions. In each scenario the intention of the respective medical procedure is to save a
life, and therefore the intentions are good. Neither case uses the direct act of abortion as a means to
achieve the good effect, which thus fulfills Mattison’s second requirement, and finally, both cases are
analogous in that the good gained can arguably outweigh the evil effect. Though the evil effect
(which, of course, would be the indirect abortion) is obviously a grave matter, the good effect
outweighs the evil because a life is saved. Without the medical procedures that indirectly result in
abortion, two lives would be lost in each case. In the case of the ectopic pregnancy, both mother and
child would have died had the hemorrhaging not been stopped. For Amanda, there is a 94% chance
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both transfused twins will die in-utero without the cauterization procedure. Even if one or both of
the babies did survive, however, the cost of forgoing the procedure would be massive brain damage
for both twins. Thus, because the intent in each case is to save a life while preserving the quality of
life, it seems that both cases can be morally justified by the principle of double effect and as such, I
believe that this analogy is the strongest argument on the “right” side of the argument.
In terms of the second paradigmatic case in which the couple is pregnant with fraternal
twins, the two cases are analogous in that both involve a woman who is pregnant with twins, and
both women must decide whether to selectively abort only one of the fetuses. The cases are highly
disanalogous in terms of the intentions and reasons for pursuing the abortion, but that both
analogously involve abortion is an important comparison to make. A second analogy that can be
drawn is that for both cases, all of the fetuses involved have a chance of surviving. The cases are
disanalogous in that the couple’s fraternal twins will be healthy whereas Amanda’s transfused twins
will be brain damaged, but the fact that death is not inevitable for any of the embryos is a strong
analogy to draw. On the side of the “wrong” paradigm, then, I think the strongest argument is not
only that abortion (which is inherently wrong) is seen as an option, but that each of the involved
embryos has a chance (though perhaps not a decent one) of surviving if carried to term.
The case of Amanda’s transfused twins is unique in that allowing the pregnancy to continue
does not pose a risk to the mother’s health, but rather to the health of the recipient baby. Amanda’s
case is also considered unique because while both fetuses face a very good chance of death without
the cauterization procedure, death is not an absolute certainty. Brain damage is a certainty without
treatment, but unfortunately, the scope of the damage cannot be known. This does, however, raise
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questions regarding what ethical duty we have to protect one’s quality of life, and this is perhaps
what renders Amanda’s case so unique.
Step 4: Weigh the Analogies to Reach a Practical Moral Judgment about the Case at Hand
I believe that by using both practical judgment and the paradigm cases as a guide, the
selective abortion of the donor twin by cauterizing the coronary connection is unethical. This
decision was a difficult one to come to, especially since Amanda’s case is so dissimilar to the
paradigmatically “wrong” case that it was compared to. However, even though the intention of
cauterizing the coronary connection between the twins is good, it does not justify the fact that one
baby would die to ensure the other would live. In this case, I believe that the key factor to keep in
mind is that both twins have a chance of surviving, even without medical intervention. According to
the ERD’s, medical treatments that result in the death of an unborn child are only morally
permissible when “their direct purpose [is] the cure of a proportionately serious pathological
condition of a pregnant woman” (pg. 23). In the case of the transfused twins, the pregnant woman is
not at risk, and the fact that both twins have a chance (albeit a slim one) of surviving renders the
serious pathological condition disproportionate to the proposed corrective actions.
The strongest argument for the moral justification of cauterizing the blood vessels was the
aforementioned application of the principle of double effect. However, because both twins can
survive, to effectively kill one of the fetuses is a disproportionate evil that cannot be outweighed by
the good of ensuring one child lives at the expense of the other’s life. A second counterargument is
that without the procedure, if the babies survive they will both be born with extensive brain damage.
However, according to the Catholic social teachings, abortion is always wrong. Even if definite birth
defects are known, the fetus is still considered to be a living human being, and as such is entitled to
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all of the rights, dignity, and respect that human life entails. A judgment made about that particular
child’s future quality of life is not reason enough to allow his or her sanctity of life to be flippantly
violated. As such, even though the transfused twins will be born with brain damage, the abortion of
one fetus to protect the other is not justified. Thus, despite the many disanalogies in intention
between Amanda’s case and the paradigmatically “wrong” one, the decisive fact remains that both
cases involve an unnecessary abortion, and the sanctity of human life must always be respected
whether there are potential repercussions or not.
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Works Cited
Gilbert, Scott F. Developmental Biology. [8th Ed.]. New York: Sinauer Associates Inc., 2006.
Mattison III, William C. Introducing Moral Theology:True Happiness and the Virtues. Grand
Rapids, MI: Brazos Press, 2008.
United States Conference of Catholic Bishops. Ethical and Religious Directives for Catholic
Health Care Services (4th Ed.). [Brochure]. Washington, D.C.: 2001.
Urig, M.A., Simpson, G.F., Elliot, J.P, and Clewell, W.H. “Twin-twin transfusion syndrome: the
surgical removal of one twin as a treatment option.” Journal of Fetal Therapy 3.4 (1988): 185
– 188.