Six Kids, Eight More: Ethicists Speak Out

Ethicists and fertility docs mull the ethics of the California octuplets case.

January 30, 2009, 10:45 AM

Jan. 30, 2009— -- After learning that the California woman who gave birth to eight babies Monday was already a mother of six, ethicists and fertility experts said that her so-called mega-multiple pregnancy was even more troubling.

Particulars of the case remain sketchy. Neighbors have told ABC News that the woman is a single mother in her 30s whose first name is Nadya. Hospital staff have refused to release the name of the mother, also declining to comment on whether she had received fertility drugs that have been linked to instances of multiple births.

But the details that have trickled from sources close to the mother have made this already unusual case even more shocking, experts say. The woman's mother, Angela Suleman, told the Los Angeles Times that her daughter had indeed undergone fertility treatments. Moreover, she said that her daughter had an operation last year to have embryos implanted in her uterus, suggesting that an in-vitro fertilization (IVF) procedure may have been involved.

Suleman also has said that when the woman learned she was carrying multiple babies, she opted not to reduce the number of embryos.

University of Pennsylvania bioethicist Arthur Caplan said the new information brings several ethical concerns into play, not the least of which is the question of why a woman who already had six children would have a medical procedure that allowed her to have eight more.

"In my view, it would be irresponsible to treat a woman who was fertile with infertility drugs or techniques," he said. "It is not clear if the six children are hers or adopted or foster kids or what. But if they are hers, then something very unethical may have happened."

And then there is the specific matter of IVF. While fertility experts originally told ABC News that they suspected that the multiple pregnancy was likely the result of drugs designed to make a woman release many eggs at once, increasing her odds of pregnancy after sex, it appears possible now that an actual operation was involved. That would dramatically increase the likelihood of such a risky and costly pregnancy.

'Arrested for Malpractice'

"[Experts] would be astounded if a fertility specialist actually implanted eight eggs," ABC News medical contributor Dr. Tim Johnson said on "Good Morning America" today. "Current guidelines, which are guidelines, not law, would suggest between one and four. ... A vast majority of experts would say that [implanting eight] is bad practice."

Likewise, bioethicist Caplan Tuesday told that, "anyone who transfers eight embryos should be arrested for malpractice."

Neonatal experts were equally concerned.

"Someone with six children is not an obvious candidate for fertility treatments," said Dr. Ian Holzman, chief of newborn medicine at the Mount Sinai School of Medicine in New York. "Because multiples are at increased risk of prematurity and all of the complications associated with prematurity, such a decision is not one taken lightly."

"The physician was irresponsible or the woman ignored all advice, and both are unacceptable," agreed Dr. Siva Subramanian, chief of neonatal and perinatal medicine at Georgetown University Hospital in Washington, D.C.. "We need to curb the idea that this is some kind of heroic or miraculous thing by the press."

In the United States, however, there is nothing illegal about adding eight children to the six you already have. And doctors point out that while doctors are free to advise mothers against mega-multiple pregnancies, there is no rule that says mothers must take that advice to heart.

"In general, doctors cannot force a patient to make a decision, though most [doctors] have a lengthy conversation with the patient," said Dr. Geeta Swamy, a maternal-fetal specialist at Duke University Medical Center in Durham, N.C.

Steven M. Donn, director of the Division of Neonatal-Perinatal Medicine at the University of Michigan Health System, said that for many mothers who opt for fertility treatments, the decision to selectively terminate some fetuses is anathema.

"If indeed this woman was an infertility patient and got pregnant, and then the first thing that they asked her to do is to terminate some of the pregnancies, this is probably very incongruent for her," he said. "It's extremely difficult for an infertile woman, once she conceives, finally, to think long-term."

Significant Religious Convictions

Still, if the six kids in question are indeed the woman's biological children, it is clear that she was, at least at some point, fertile. At this point, other factors may come into play.

"You can often tell who is going to flat-out say that they are not going to do it," Swamy said. "These are often people with significant religious convictions. ... For them, it is often all or none."

These convictions might endure, even in the face of the serious risks that mega-multiple pregnancies entail, Georgetown's Subramanian said.

"Even without discussing the issue of fetal reduction, which is controversial in its ethical, moral and religious arenas, any number over two or three fetuses is detrimental to the mother's health during pregnancy and after," he said. "It is also detrimental to the fetuses where they compete for the resources with some failing to get enough nutrients."

As it now appears likely that the mother and her eight new babies will share a three-bedroom apartment with six other children, most people could also find themselves grappling with the notion of how a mom with 14 kids could possibly make ends meet.

"Right now multiple births are being treated as a 'lark' on television series and in some news reports," Pennsylvania's Caplan said. "But this 'Brady Bunch' attitude obscures the risks and dangers, especially when many vulnerable babies are added to a family that is already very large."

Massive hospital bills aside, the newly expanded family will also face day-to-day expenses such as food, clothing and proper housing. Medical care could also be a major consideration, as premature babies, on average, require more health care services throughout their childhoods than their full-term counterparts.

Subramanian noted that whether the mother relies on private insurance or Medicaid, "it is still a tremendous resource utilizer, especially if she has had six other kids."

Said Caplan: "It is important that social services check into this story to see that the other children are not being neglected."

Keeping Burgeoning Families at Bay

So what can be done to curb what some call an abuse of medical technology? Caplan said reform is needed to ensure that such an episode is unlikely to happen again.

"There is still insufficient oversight of who can use infertility services in this country, what they are told about the risks of mega-multiple pregnancies, what they are told about their options to manage mega-multiple pregnancies and with what force by doctors and what sort of follow-up care the family and babies receive," he said. "Nor is there enough attention being paid what sort of support society is or is not willing to extend to families who choose to have many children all at once."

Donn said one idea is for patients to sign a contract with their doctors indicating that they understand the potential outcomes of a fertility procedure and what steps they are willing to take if they find themselves with a potential mega-multiple pregnancy.

But until more details about the California case in particular become clear, Mount Sinai's Holzman said it is unlikely that the public will have a clear picture of what exactly happened and why.

"In the end, this story is one that feels wrong, yet the real meat is in the details, which none of us have," Holzman said. "Ethics is about motivation, intention and justification, and it is hard to support or criticize without details."

Reporting from Mike von Fremd, Lauren Sher and Lee Ferran contributed to this report.

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