“Octomom”: Ethical Problems in the Nadya Suleman Case

Jan Hare, Ph.D.

Human Development and Family Studies Dept.

The Wild West of Medicine: Infertility Industry

 Unresolved: Is infertility a disease or a misfortune?

 Many clinics oversell their success rates  No centralized licensing to enforce guidelines  No regulation of infertility industry 

Anything goes if patients can pay.

In-Vitro Fertilization

 Begin oral contraception  GnRH Agonist Administration  Ovarian Stimulation  Monitoring of Follicle Development  Final Oocyte Maturation and hCG Administration  Transvaginal Oocyte Retrieval  Insemination of Oocytes  Embryo Transfer  Progesterone Supplements  Pregnancy Test

Patients’ “dispositional authority” over leftover embryos

 Whether or not to freeze  Whether either parent can use in event of death or divorce  Whether their frozen embryos can be    discarded donated to other would-be parents donated to research

Laws regarding practice

 United Kingdom: no more than 2  Australia: no more than 3  Italy: only 3 eggs fertilized in vitro for married women, all must transfer simultaneously.

 United States: no centralized licensing, no control authorities, no laws

Professional Guidelines

 Society for Assisted Reproductive Technologies (SART)  American Society for Reproductive Medicine (ASRM)  Number of embryos transferred  Child-rearing ability of patient

Day 5

Guidelines pertaining to embryo transfer

35-37 38-40 >40 <35

Cleaving Embryos 1 1-2 Blastocysts 2 2 3 2 5 3

The Problems

 Multi-fetal pregnancy  Risk of poor outcome directly proportionate to number of fetuses in womb.

 Care-giving load:  168/hrs in week. 6 month old triplets require 197.5/wk of mother’s time for care.

The Perfect Storm

 Plunging national economy  Near bankruptcy of California  Fragile state of our health care system  Into this: the birth of octuplets in Bellflower, CA

Nadya Suleman

 Age 33  Single  6 children via IVF (4 singletons, 1 set twins)  Ages 3-7, 1 child autistic  Unemployed, receiving public assistance  Living with parents – partially estranged  Medicaid to pay medical costs

2008 treatment

 6 embryos thawed, transferred  All implanted  2 split  Kamrava offered Suleman MFPR; she refused  Result: 1/26/09 birth of octuplets at 31 weeks  Birth weights: 1# 8oz – 3# 4 oz

West Coast IVF Clinic

 Michael Kamrava

Questions fall into 3 categories

 Role of Reproductive Endocrinologists  Distributive Justice  Regulation of ART

Ethical Questions

 Related to role of reproductive endocrinologists:  Who should make the ultimate decision regarding how many embryos to transfer?

 Should Dr. Kamrava have accepted Ms. Suleman as a patient?

 Related to distributive justice:  Who bears the cost of delivery and NICU?

 Who bears the cost of services (sometimes lifelong) for children with special needs?

Legal questions:

 Do the children have a right to seek financial compensation from the fertility clinic/hospital?

 Do the children have a right to financial compensation for any television/book deals relative to their conception, birth and lives?

In her own voice

 Nadya Suleman interview with Ann Curry

Ethical Questions

 Related to role of reproductive endocrinologists:  Who should make the ultimate decision regarding how many embryos to transfer?

 Should Dr. Kamrava have accepted Ms. Suleman as a patient?

 Related to distributive justice:  Who bears the cost of delivery and NICU?

 Who bears the cost of services (sometimes lifelong) for children with special needs?

Arguments

 Adoption standard should be applied to fertility treatments.

 Hijacking health care $ by irresponsible decisions

     

References

Armour, K. & Callister, L. (2005). Prevention of triplets and higher order multiples: Trends in reproductive medicine. J. Perinat Neonat Nurs, 19, 2, 103-111.

Kurtz, M. (2009). More than a village: Meeeting the health care needs of multiples. Hastings Center Report, 39, 3, 25-26.

Johnston, J. (2009). Judging Octomom. Hastings Center Report, 39, 3, 23-25.

Murray, T. (2008). Commentary: Are eight babies more than enough? Retrieved : http://www.cnn.com/2009/HEALTH/02/04/murray.octuplets/index.html

Robertson, J. (2009). The octuplet case – Why more regulation is not likely. Hastings Center Report, 39, 3, 26-28.

Williams, P. (2009, March 2). Eight is enough. The Nation, p. 9.