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Ethical Issues

Posted Apr 09 2009 7:16pm


This week, the blogosphere and news media have been abuzz with the story of Nadya Suleman, the mother who gave birth to octuplets. This set of octuplets marks only the 2nd set of live born octuplets in the United States. When the story first broke, the initial reaction of many was that of joy. Details were not known regarding the background story, and for all anyone knew, this was an infertile couple who had finally achieved their dream of having children. As a neonatal nurse, even upon hearing the initial story, my mind began racing about what could possibly be going on behind the scenes with these babies. They were born at 30 weeks, weighing between 1 pound 8 ounces to 3 pounds 4 ounces, with a staff of 46 medical personnel in attendance. The day after delivery, news reports were stating that all of the babies were doing well. When the discussion came up around my family's dinner table about this news, I immediately spoke up to say that only time could tell how the infants would do: premature infants often have a honeymoon phase for the first few days of life, but then start to develop more severe problems after this period as their bodies realize the full weight of having to survive outside the womb without having been fully developed. While babies born at 30 weeks often end up doing well, having multiples means that the babies likely have not truly achieved 30 weeks' worth of development. I could not trust that the "all is well" news reports were going to last, as having 8 babies at 30 weeks gestation still poses significant risk. Thus far, however, officials from Kaiser Permanente continue to state that the babies are doing well. I certainly hope and pray that this continues to be the case.

As the past week has gone by, more and more details have come out about the background of Nadya Suleman. There are numerous articles to link to on reputable news sites, and I have been following all of the major news outlets to try to read about the most recent updates. This is the latest from ABC News on the story of this family. Apparently Nadya Suleman is a 33 year old divorcee who lives with her parents, and she had 6 children prior to undergoing in vitro fertilization for the octuplets. As it turns out, all 14 of her children were apparently via in vitro fertilization from the same sperm donor, though the sperm donor is apparently not Suleman's ex-husband. Suleman has an undergraduate degree in Child and Adolescent Development, and was apparently going for a masters degree in counseling. This story from the Times Online, UK, broke the news that Suleman has contacted an agent to try to arrange interviews with Oprah and Diane Sawyer, and wants $2 million in exchange for the story. Suleman apparently also wants to become a television childcare expert, according to the Times article.

So, the ethical issues here keep piling up! Here are some of the ethical questions that come to mind, regarding this story:

*Did this mother truly undergo IVF (as opposed to taking fertility drugs), and if so, what physician would implant 8 embryos in a 33 year old with 6 children no older than age 7? (Varying reports have said that a reproductive endocrinologist could have implanted as few as 5 embryos, having some of them split to yield 8 fetuses, but other reports state that for her to have 8 embryos take, she probably had many more than 8 embryos implanted.)

*Was the mother honest with the fertility clinic about having 6 other children? Even if she somehow hid the fact that she had 6 other children from the fertility clinic, it still goes against guidelines to implant even as many as 5 embryos in a woman of this age.

*Should this mother have been sent for a psychological evaluation prior to implantation?

*Who will pay for these children?

*Can a single mother, whose family apparently declared bankruptcy within the last year and lives in a 3 bedroom home, possibly care for 14 children? And if some news reports are to be believed, the grandmother has stated that she won't be sticking around once the mom and babies are discharged from the hospital.

The list could continue on with a number of ethical questions and dilemmas. One issue that has been discussed by various news reporters and bloggers is that of reduction. Selective and Multifetal Pregnancy Reduction are terms that are sometimes used interchangeably, although they may take place for differing reasons. Some families may choose to terminate a fetus which shows likelihood of congenital defect, thus selecting which fetus to terminate. In Multifetal Pregnancy Reduction, often a fetus is randomly selected to be terminated, even without evidence of congenital anomaly, in order to reduce high order multiple gestation and the risks to mother and babies. This article from the University of Virginia Health System lists some of the risks of a high-order multifetal pregnancy, including preterm labor, pregnancy induced hypertension, hemorrhage, and other such risks to the mother. Risks to the babies are many, including prematurity, twin-to-twin transfusion, birth defects, and developmental problems such as arthrogryposis which results in joint contractures. One situation that can lead to arthrogryposis is a lack of room for the fetus to properly develop due to multiple fetuses. There are many other potential causes for arthrogryposis, and, in fact, all of the things that are risks to the baby in high-order multifetal pregnancy can occur in the absence of a high-order multifetal pregnancy, but they are more likely to occur in the presence of such a pregnancy.

These risks lead to the debate of whether or not multifetal pregnancy reduction should have occurred in the case of the octuplets. I would like to first state that in an ideal world, the issue of multifetal reduction would be moot because the responsible reproductive endocrinologist would follow the guidelines for implanting only 1-2 embryos in a woman of Suleman's age. Responsible implantation of embryos is one way to prevent the issue of multifetal reduction, but this does not help cases of high-order multiples caused by fertility drugs. In reality, fertility drugs are a more-likely cause of high-order pregnancies because they require careful monitoring to assess the number of follicles present after ovarian stimulation, and if a high number of follicles are present, then further treatments are postponed and the mother is advised to refrain from intercourse until the risk of impregnating this number of eggs has passed. However, avoiding high-order multifetal pregnancy with fertility drugs requires that a number of things go right:

*Proper monitoring of the mother to assess number of follicles present

*Proper identification of number of follicles and cessation of further treatment

*Because some mothers are able to ovulate, once the follicles are present, in spite of further treatment, the mother must be advised to avoid intercourse until the eggs are past the point of fertilization.

*The mother must do her part: show up for monitoring, heed the advice of the physician, and so on

If all of these things were done, then the reality should be that high-order multifetal pregnancies are the exception, and definitely not the norm. If this were the case, then the issue of multifetal reduction would be not such a large one. Unfortunately, due to the high cost of in vitro fertilization, some women press their physicians to implant more than the recommended number of embryos to increase the chances that they will have at least one embryo take. I can understand this - on a tight budget, one cannot necessarily just hope for the best with only 1-2 embryos when this may be their only shot. However, if a physician and woman decide to proceed with implanting more than the recommended number of embryos, then they must have a plan in place for how they will manage the care if all of the embryos do, in fact, take place. The downside to multifetal reduction is that it could jeopardize the other embryos/fetuses, and it has a huge psychological impact on the parents, who have chosen to terminate the one thing they have wanted so badly. All of these things must be taken into consideration when fertility treatments are begun.

I am personally not here to say that multifetal reduction is right or wrong. Should Nadya Suleman have reduced when she found out that she was pregnant with at least 7 babies? I believe that the decision at this point is up to her. I don't believe that anyone should be forced into reduction, but at the same time, the parents must be fully informed of the risks of proceeding with a high-order multiple pregnancy. My next posts are going to follow up on this issue. I would like to further discuss the benefits and risks of multifetal reduction in greater detail.

The birth of these octuplets have brought to light a number of major ethical issues. Even without knowing any background information on the mother, there are still issues to consider regarding fertility treatment, IVF, the number of embryos implanted, multifetal reduction, and so on. Knowing the mother's history provides an even greater number of ethical conundrums! This is a single mother who is not financially stable with 6 children under the age of 8. These things all must be taken into consideration when examining this event.

Many will argue that it is none of our business what this mother has chosen to do. I disagree. The birth of these octuplets, under these circumstances, may have a very far-reaching impact. This could result in legislation regarding fertility treatments (which may or may not be a good thing - and a topic for debating at a later date). There are financial issues to consider: Who will pay for these children? Is it the taxpayer? Is it right for this mother to receive a celebrity contract to help pay for the cost of these children? Is celebrity status harmful to the children? What does this event mean for the future of others who seek fertility treatments? What does it mean about personal responsibility and choice?

Is it fair if this mother receives "handouts" (for lack of a better term) just because she chose to have 14 children that she could not financially, emotionally or physically care for all on her own? No. It's not fair. There are many people who struggle in this country and who make responsible choices that are not given a single thing to help them in their plight. HOWEVER, that being said, we need to also consider the welfare of the children. They are here, and we cannot change that. In continuing down this path, we must consider doing what is the best thing for them. It certainly will not benefit the children for everyone to exile this mother and force her to struggle through on her own, even if this is how we personally feel she should be treated in lieu of her choices. I'm not saying that a celebrity contract is the best thing for them, either, however. We've all seen that children growing up in the limelight don't always have the most well-adjusted of childhoods! What is the case, is that this mother is going to need help and support to raise all of these children. This must be provided, but we cannot do so and just ignore the downside to this situation. We still must use this as a learning experience. If anything, we must take away from this situation that there are ethical implications that need to be examined in order to prevent this type of thing from recurring in the future.

Other blogs reporting on this topic:

Suture for a Living's Ramona Bates writes about Eight Too Many

Musing of a Distractible Mind's Dr. Rob writes about Don't Forget the Kids

Fat Doctor writes about Eight and Six

Medical Quack: Obsessed With Having Babies?

Robin, of Survive the Journey, writes: Nadya Suleman's Octuplets: How many is too many?

Moof, from All Blogged Up: A Moof's Tale, writes Ooooopsie

Dr. Cris from "Scalpel's Edge" writes Making Babies or Saving Lives
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