Wednesday, May 13, 2009

Octomom, Ethics, and Health Care Limits

This morning I participated in the Massachusetts Association of Health Plans (MAHP) ethics forum. MAHP has been sponsoring 3-4 ethics forums each year since 2002, open to Massachusetts health plans and interested others. Our topic today was "The Octomom Case: Who Should Decide About Fertility Treatment?"

We used the well publicized case of Nadya Suleman ("Octomom") who gave birth to octuplets as a result of in vitro fertilization as an avenue into large issues of health system ethics. Here's how the invitation defined the topic:

There are many ethical dimensions presented in this case. The first is “limits” itself. Should there be enforceable limits to fertility treatments (as opposed to guidelines)? Are we willing to limit choice? And if so, how far are we willing to go? Few would endorse China’s policy of one child per couple, but we intuitively understand that in vitro fertilization resulting in 14 children is too many. Who should set the limit: the patient, the doctor, government or society – or health plan? And is it the same limit for everyone – or are there different limits for those who can afford to pay all costs themselves?
We had decided to open the forum with a mini-debate. I took the roles of Ms. Suleman and Dr. Kamrava, her fertility specialist. Although I've long argued that society and the health professions have a responsibility for stewardship of societal resources and that limits are an ethic ethical obligation, not a moral abomination, I was impressed with how readily I could enter into a role I do not endorse.

The argument I made as Ms. Suleman was based on (a) love of children, (b) not wanting to discard the six embryos that were implanted, (c) my fully informed consent to the procedure and (d) the high value we place on choice in the U.S. As Dr. Kamrava I argued that we ask physicians in the U.S. to respect the uniqueness of each patient. Ms. Suleman loved children, wished for more, and previously had had single births (and one set of twins) when I transferred six embryos to her. I directly responded to the criticism that I had not followed American Society for Reproductive Medicine guidelines by quoting the relevant passage:
For patients under the age of 35 who have a more favorable prognosis, consideration should be given to transferring only a single embryo. All others in this age group should have no more than 2 embryos (cleavage-stage or blastocyst) transferred in the absence of extraordinary circumstances.
I argued that the intensity of Ms. Suleman's love for children and her commitment to not destroying the six remaining embryos, combined with our experience in her previous cycles, constituted "extraordinary circumstances."

The contrary position in the debate was amplified by the group's discussion.

  • Individual preference ("patient autonomy") is very important, but it should not be allowed to trump all other values.
  • Being part of a multiple birth increases risks for the unborn child. Even though our society allows abortion, it can legitimately decide to limit conception as a way of protecting child health. We protect children after they are born. Why not do so before they are conceived?
  • Even if advances in technology eliminated the risks associated with multiple births, so that harm to the potential child would not be a consideration, our resources are not unlimited. Future costs to society should be part of the equation and can be a legitimate basis for establishing a limit.
  • We can't expect physicians to be the limit setters. They are (and should be) sensitive to their patient's values and wishes. Many fertility specialists would welcome external limits set by society.

The forum discussion recognized how strongly we in the U.S. value "life, liberty, and the pursuit of happiness." There was some hope that the recession would help us add heightened concern for the commons to our portfolio of guiding values. The group took note of the fact that several European countries regulate the number of embryos that can be transferred - some to two and some to one. They also limit the number of eggs that can be fertilized, which avoids the issue Nadya Suleman invoked - the presence of multiple untransferred embryos.

At the very least, the Octomom case may have created public readiness to accept limits set by insurers on the basis of the American Society for Reproductive Medicine guidelines.


Sprudeln said...

I still do not understand why the focus is on her ability to pay for her 14 children, rather than the fact that she had 6 embryoes transferred at one time.

She could have had 1 or 2 transferred, had a healthy, safe, and normal pregnancy, and then transferred 1 or 2 more...

We would have never heard of her or her doctor and her children would have been put at much, much less risk.

The fact that a doctor allowed such a medically dangerous (and wholly avoidable) situation to occur is absolutely outrageous.

eric said...

I agree with Sprudeln. Usually, the details of a case de-escalate the ethical and political arguments and bring decisions down to earth, to practical, medical considerations. Tremendous risks were taken to have the eight babies. The survival of the mother, let alone the fetuses, was at stake. Who would have cared for the previous six children, had the octomom died?
Other moral arguments must have come up in the forum. Is it love or greed that motivates more child-bearing in this case? Is it patient-centered care or self-aggrandizement to accommodate such extraordinary wishes?

Jim Sabin said...

Hello Sprudeln and Eric -

I agree with Sprudeln's view of what should have been done medically and whose actions were outrageous - namely, the physician's. Nadya Suleman is entitled to have her wishes, but a responsible physician should have been prepared to say no and explain why.

In terms of Eric's question about other moral arguments that came up at the Forum - there were speculations of exactly the sort you imagined re the motivations on the part of Nadya Suleman and Dr. Kamrava. If we had actual statements from either the patient or the doctor I would have cited them, but didn't want to bring speculations about private motivations into the blog. That's a theme I'm especially sensitive to as a psychiatrist. The code of ethics for the American Psychiatric Association includes the following:

"On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."