Ethics and the California octuplets case

When news about a woman who had given birth to octuplets last week first hit the airwaves, the story was that all had survived the premature Caesarean delivery, and the eighth kid was one doctors hadn’t even known was coming! Surprise! Within days, however, as we learned more about the birth family – that the mother was single and already had six children at home – the tone changed, and a range of ethical questions emerged. Karey Harwood, author of The Infertility Treadmill: Feminist Ethics, Personal Choice, and the Use of Reproductive Technologies, discusses just these kinds of ethical issues in her book. In a guest post here, she addresses the specific case of Nadya Suleman.

Some of the most important facts of the California octuplet case may not be known until the first movie is made telling Nadya Suleman’s story. According to the publicist Suleman has hired, the mother of fourteen is keeping some of her story “reserved” for now.

In the meantime, the “facts” that have emerged about Suleman and the conception of her octuplets are somewhat murky. Her mother has been reported as calling her daughter “obsessed” with having children, raising the possibility in some people’s mind that she is mentally unfit or unstable. Yet others, her spokesman included, attest to her being quite bright, very engaging, the ideal patient.

We know that Suleman gave birth to eight babies. But what exactly were the circumstances of their creation? Her mother was reported as saying that fewer than eight embryos were implanted in Suleman, but that they “multiplied.” Nadya Suleman herself now says that six embryos were implanted at once, and though it is a rare occurrence, two of the embryos divided to make a total of eight. Suleman also revealed that she had six embryos implanted for each of the previous IVF cycles that resulted in her six older children.

Multiple embryo transfer is a practice unequivocally discouraged by the American Society for Reproductive Medicine, which writes the practice guidelines for doctors in this field. Their recommended limit for a woman Suleman’s age is 1-2 embryos transferred at a time, but their recommendation is nothing more than that. There are no penalties for doctors who implant more. Multiple embryo transfer is more stringently regulated in the United Kingdom, where the legal limit is two and an even more cautious norm of “one embryo at a time” is emerging. But despite the absence of similar regulations here, U.S. doctors are well aware of the risks of a multiple-fetus pregnancy. Why would Suleman voluntarily engage in such a risky pregnancy and why would her doctors acquiesce to assist in such a risky plan?

Whatever the motives of Suleman and her doctors, one of the most controversial ethical questions raised by this case is whether anyone other than the competent consenting parent-to-be ought to make judgments about the kind of conditions into which a child is born. Is a single-parent family inherently inferior to a two-parent family? Is a large family inherently inferior to a small one? Does a child deserve “better” and if so who defines what that is?

While the Catholic Church proceeds unwaveringly in defining the ideal conditions into which a child is born, reiterating its teachings in the recent document Dignitas personae, other voices in the public debate are wary of insisting on a two-parent, heterosexual, married couple as the true ideal. Most people, if they are brave enough to venture a judgment at all, will insist on certain qualities for a healthy family – like the mental stability of the parent(s), the ability to provide for the material needs of the child, and the ability and willingness to love the child – rather than insisting that these qualities can only be found in a family form of a particular shape.

Suleman, a single mom, should not be automatically judged by virtue of her singleness. But whether she has brought her 14 children into the “best” conditions very much remains to be seen.

Given that most commentators do not want to preemptively judge Suleman a bad parent, the greater ethical concern has centered on the potential harm done to her offspring by virtue of entering the world as octuplets at about 30 weeks gestation. The data about the risks of multiple births are firm. According to the CDC, the infant mortality rate for multiple births is more than five times greater than the rate for single births (a difference in 2004 of 30.46 deaths per 1000 live births versus 5.94 deaths per 1000 births). Of course everyone is grateful that Suleman’s octuplets are surviving, but we do not yet know what, if any, impairments they will suffer. There are risks of vision problems, learning disabilities, cerebral palsy, problems with organ development, and other developmental delays, as has been widely reported.

In the end, what bothers me the most about this case are the bad faith arguments of fertility doctors who wash their hands of moral responsibility: “I don’t think it’s our job to tell them how many babies they’re allowed to have. I am not a policeman for reproduction in the United States. My role is to educate patients,” claimed Dr. James Grifo, professor of obstetrics and gynecology at the NYU School of Medicine, who was interviewed for his opinion about the Suleman case but not involved in it. Since when have doctors abandoned their role to guide patients with good judgment about what constitutes an unacceptable medical risk? Doctors who rationalize their actions by trumpeting patient “free choice” understandably lead the public to suspect at least one ulterior motive: the profit to be made in servicing reckless patient-consumers.

In addition, I have serious problems with the injustice of allocating any medical resources, whether publicly or privately financed, for the creation of multiple gestations (let’s say triplets and higher). I cannot help but think of the millions of uninsured Americans, including millions of uninsured children, who suffer grievous harms on a daily basis due to their lack of access to even the most basic health care, as well as the many, many infertile couples who lack the financial means to afford even one round of IVF, let alone seven. The resentment Americans feel toward Nadya Suleman and her doctors is very real, and I believe it is not unjustified. We cannot let our earnest (and commendable) desire to be respectful of individuals’ choices blind us to the social impact of an accumulation of selfish individual choices. This is simply not a fair distribution of resources. And the coming onslaught of movie and book deals that will bring further profit to Suleman is nothing short of reprehensible.

Karey Harwood
North Carolina State University

ed. update 2/16/09: this article has been cross posted at

ed. update 2/25/09: please see Harwood’s follow-up post as well