Don't Blame Momma.
Today from the Philadelphia Inquirer, Arthur Caplan has published an opinion piece on the issue that has all of bioethics (and the entire country) talking: the famous (or infamous) California octuplets.
So unless you've been flying in an airplane continuously for the last 96 hours or don't own a television, you know the story, but below is Caplan's take--given only the way Arthur Caplan can give it: by giving us insight, but also telling us as a country how to get our act together so that other women can't ever get in the same predicament by falling into the wholly unregulated Wild West of the American fertility treatment system.
The column is below in its entirety because it wouldn't do it justice to excerpt it. Caplan says:
"Something has gone terribly wrong when a 33-year-old single woman - who has no home of her own, no job, and a mother who worries her daughter is "obsessed" with having children - winds up with 14 of them. And all are under age 8, including eight newborn babies now in a neonatal nursery in various states of prematurity.
Examining what exactly went wrong may shed some light on what ought to be done. If doctors cannot prevent such a shambles from recurring, then society must.
The woman in question, Nadya Suleman, lives with her parents in a small home near Los Angeles. She has had infertility problems linked to blocked Fallopian tubes. She can make eggs, but they cannot be fertilized naturally because of the blockage.
Suleman apparently used donated sperm and in vitro fertilization to create all the embryos that became her children. She underwent treatment to cause her to produce many more eggs than the normal one per month, and they were surgically removed from her body and fertilized in lab dishes. Some of the resulting embryos were put back into her body, and that is how her first six children were made.
Unhappy with only six, Suleman sought further fertility treatment and had an additional eight of her embryos defrosted and implanted. They produced the now famous octuplets who, after a Caesarean section, are in intensive care at Kaiser Permanente Medical Center in Bellflower, Calif. Sadly, there is no known case of octuplets in which all escaped severe disabilities.
The most obvious questions raised by this sad saga include: How did Nadya Suleman become a fertility patient? And how did she get eight embryos implanted when she already had six young children to care for in a tiny house, with no partner and no income?
Some fertility doctors would answer that it's not their job to decide how many children a person can have. Jeffrey Steinberg, medical director of the Fertility Institutes, which has clinics in Los Angeles, Las Vegas and New York City, was quoted as saying: "Who am I to say that six is the limit? There are people who like to have big families."
James Grifo, a renowned fertility specialist at New York University, had little time for those wondering why Suleman was a patient. "I don't think it's our job to tell them how many babies they're allowed to have," he reportedly said. "I am not a policeman for reproduction in the United States."
With all due respect, the idea that doctors should not set limits on who can use reproductive technology to make babies is ethically bonkers.
If someone comes to a clinic with a history of child abuse, active drug addiction, and a rap sheet with serious felonies, should the doctor simply say: "If you have the money, I will make all the babies you want"? That gives cash and carry a whole new meaning.
Doctors have an obligation to consider patients' requests for treatment, but they do not have to honor them. One very good reason not to do so is if a doctor believes that what the patient wants would put children at grave risk.
Putting eight embryos into a woman is exactly that - putting kids at grave risk. Putting eight babies into the family of a single mom already trying to cope with six other young kids, with no money and little help, is putting kids at grave risk. The doctors who allowed Nadya Suleman to receive multiple embryos engaged in grossly unethical conduct.
The other major ethical problem raised by this story is the hijacking of health-care dollars by someone acting irresponsibly.
Suleman had to know that starting a pregnancy that might create eight tiny lives was to risk killing herself, as well as killing or severely disabling one or more of the babies. Fortunately, she made it through the pregnancy. But the cost of neonatal care for her eight new children probably will exceed $1 million.
When they are discharged from intensive care, more millions of dollars in medical costs likely await, not to mention the help Suleman will need just to handle all of her children's basic needs.
Society needs to discourage mega-multiple births. And it is clear what needs to be done to accomplish that.
If the medical profession is unwilling or unable to police its own, then government needs to get involved. We already have rules governing who can get involved with adoption and foster care. Shouldn't these minimal requirements be extended to fertility treatment? And shouldn't some limit be set on how many embryos can be implanted at one time, along with some rules about what to do with embryos that no one wants to use?
Other nations, such as Britain, keep a regulatory eye on reproductive technologies and those who wish to use them, knowing their use can put kids at risk in ways that nature never envisioned. We owe the same to children born here."
Summer Johnson, PhD
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That woman was out of her mind thinking she could care for even one more child when she already has six, let alone EIGHT new babies! No partner, no home of her own, no income?! Really? Don't we teach our kids that you need those 3 things before you should consider having children? My 3-year-old gets it, but a grown woman doesn't? I agree there should be something to regulate this sort of thing--even if all those poor babies live, they'll most likely be diables and have to live on the system.
- by Apryl on Feb 6, 2009 at 3:14 PM | link
Arthur has been highlighting our collective failure to regulate the fertility business (and the failures of effective self-regulation within the profession/business) for 25 years or more. He was right then, and he is right now. This latest episode may be sufficiently egregious to mobilize some action, but I wouldn't count on it.
Autonomy is properly an important value/principle in bioethics, but it is not the only value, and like all values, it has limits. This case is one exemplification of that, and of the abuses to which it can be put--especially by self-interested providers of medical or quasi-medical services who justify their own fees (undoubtedly paid by others) by invoking the principle, while avoiding and sense of their own responsibilities.
How did we get here? Bioethicists were properly critical of moralistic failures to provide medical services on the basis of dubious moral (typically, read religious) principles--such as helping single women or lesbian partners to use artificial insemination to have a wanted child who would be loved and well cared for. Coupled with the rhetoric of choice, carried over from the abortion debates, doubt was cast on any invocation of moral principles (vs. the "perfectly acceptable" principle of the patient's inability to pay) by professionals in the context of reproductive services. One can understand the concern, and the need to reshape prior moralistic practices. But as is so often the case, a simple slogan--here, patient autonomy or "choice"--quickly exceeds its proper boundaries, and is invoked to justify the abscence of any exercise of responsible professional judgment or concern for the common good (let alone common sense).
It is past time for bioethics to do a better job with these issues. Kudos to Arthur for persisting on these questions over many years.
- by Alan J. Weisbard (The Wise Bard) on Feb 7, 2009 at 12:40 PM | link
Leave the woman alone. I have 14 brothers and sisters and we are all doing just fine. Granted, we were not all born at the same time, but our parents wanted us and loved all of us in spite of our differences philisophically, theologically and politically. They worked hard through the good times and the bad, and despite some of the neighborhood rumblings of what should be allowed in society with respect to family size, all of us are well respected in the community and most of us have families of our own from small size to large, and we even have some adopted members of our now very extended families. If the woman decides to market her story; so what! Sounds like she is making a living to me! I am interested in her story, and as a therapist and social worker, that story will help all of society to understand lonliness, love and hope. Drop the judgemental diatribe and social directives, and allow all of us to live free in this society.
- by Steve on Feb 7, 2009 at 12:40 PM | link
I have nothing personal against ART/IVF, what I do have a problem with is using this wonderous technology for a woman who already has 6 children from previous ART/IVF, no job, no partner, and the other children under the age of 7. I saw the interview of her and commend her for wanting to continue her education, but with so many mouths to feed, children to care for, etc. how is she going to find enough time to do all the basics that need to be done.
I also have a big problem with the people contacting her to do a book or movie, or even tv show about her and the children. They are not of an age to give consent, and with everything else going on, they do not need their already too public lives to be even more so.
In the interview, she said she had 6 empbryos implanted, so there must have been at least two twinnings to make the 8 babies born. Was that not even planned for by these supposed specialists? And will these "specialists" offer free ART/IVF to other women like they did for Nadya? If not, why not? And why her?
- by Ann Lormand-Koch on Feb 8, 2009 at 11:12 AM | link
I generally feel that government regulation does not have a legitimate place in reproductive matters. But this is clearly a case where reproductive medicine has failed to police itself in reproductive ethics. When any entity creates an ethical void, that entity invites/demands that others fill that void. The void will be filled by legislators, pastors, media pundits and countless members of the blogosphere. Any claim of moral ignorance or moral indifference by those who performed this procedure attests to a lack of training in ethics and, I believe, clinical judgment.
In fact, it is well known that multiple births such as these always produce children with significant physical debility. That’s why the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology suggest that no more than two embryos be transferred to women of her age. Implanting this number of embryos, at best, represents a lack of knowledge of the medical reasons for these guidelines. At worst, it is malpractice. I believe it is malpractice. Her physician deserves to be sued for support of these children. The law is a blunt tool. But when we fail in the matter of nuance, we invite the application of a blunt tool.
- by Bob D on Feb 8, 2009 at 5:46 PM | link