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


  1. Well done, Karey. I agree strongly with most all of this. I think we need much stronger regulations, not just suggested guidelines. And regardless of what the law does or does not say, this woman’s doctors were grossly unethical. I am going to unequivocally state that there’s no way somebody with six kids between the age of 2-7 should get a single embryo implanted, much less 6 (I’ll give her that, even though I suspect the odds of two embryos dividing is astronomical). I’d love to see her fertility doctors lose their license.

  2. Thanks, Steve. I think there is a lot of inertia against regulating the infertility industry in the United States — primarily out of fear that we’ll be “policing” the intimate sphere of reproductive freedom. What’s refreshing about the U.K. is that they seem, quite sensibly, to be able to respect individual freedom while also protecting the safety of children, mothers, and society generally. Contrary to what many Americans may think, it IS possible to serve these different goals.

  3. I agree fully with this article written by Karey Harwood. I personally feel that there is no way in which Nadya Suleman’s is capable of caring for 14 children. She wasn’t even able to care for the six she already had without help from her parents. That said, even her parents ended up losing their own home in order to assist their daughter. While there may not be any laws in place to say how many embryo’s a Doctor should implant, I certainly feel that the use of common sense should play a role in this. I can’t even imagine a Doctor thinking that this woman needed more children at her age, employment status etc. Not to mention the obvious “mental status” of this women. How unethical is this doctor? I think that’s pretty obvious as well. I’m sorry, but I don’t feel America should have to support this lady and her children. This lady touts that all she ever wanted to be was a mom. Ha! She doesn’t stay at home and raise the children she has and won’t with the addition of eight more. I certainly hope that the state does step in and do what is necessary to assure that these children have the life they deserve. It would be wonderful if the “sperm donor and the Doctor” had to provide some financial responsibility in this case. Maybe then they would change their ethical and moral aspects.

  4. The fact that Ms. Suleman is being interviewed, has a “movie” deal, is probably looking for donations of diapers, a home, clothes, etc. is obscene. And how do we know she is not going to do invitro again!!! Does she have any more embroyo “children” that would fit perfectly into her family of 14 children.

    The fertility doctor has to bear some of the responsibility for this fiasco and perhaps, as others have said, he can help support these babies and their older siblings.

    Don’t tell me that the taxpayers of California are not going to contributing to the cost of the children and what insurance company is getting stuck for the hospital bill?

  5. Why didn’t this woman who loves children adopt eight of them? Lord knows there are plenty of children needing a home and if she is such a wonderful mother, she could give them all of her love and care?

  6. I have to agree entirely. I feel that this woman is being very selfish in her choices. She has fourteen children, all of whom were born due to IVF??!! There are sooo many woman out there who can’t even get pregnant and she single and jobless decides to have herself implanted with more embryos???!!!! Where did she get the means for something like this? Where will she get the means to support her 14 children? Our tax dollars! There should be something that can be done about this and even similar situations. This is a serious ethical situation and I feel that there should be some serious action taken about it. Allowing this single, jobless woman to get book deals, a movie, and even more is going to validate the fact of what she has done. While those movies and books may praise her, I say that she is wrong, very wrong.

  7. I am an RN with a certification in Neonatal Critical Care. I too am duely upset over this occurence. Not only is the health and welfare of 8 more infants in question, but who will end up paying for these 14 children’s childhood?? Chances are, it will be you and me through our tax money via the welfare system. A certain amount of moneys is given for each child one has.

    The fertility physician does have an ethical obligation to be prudent in all he or she does. Even though there is not a law against implanting as many embryos as s/he did, there is a statement in the hypocratic oath for doctors that says,
    “first do no harm”. How can 8 fetuses not cause harm to themselves and to the mother?? As a highly experienced
    neonatal nurse, I say that it is not safe at all. Humans were not made to have litters.

    The physician could easily say ” No, I am not willing to face the possibility of putting the safety and lives of any fetuses and mother at risk”.

    It is about time that humans begin to take responsibility for their own action, and I am referring to both the physician and mother of these children.

  8. Interested readers might want to check out today’s New York Times article on the subject of multiple embryo transfer and the lack of regulation of U.S. infertility clinics. Notably, Suleman’s infertility clinic has now been identified as the West Coast IVF Clinic in Beverly Hills, run by Dr. Kamrava. This clinic has one of the highest embryo transfer rates in the country as well as one of the lowest success rates in terms of live births. Given that context, I interpret a transfer of 6+ embryos at once as a brazen attempt to improve the clinic’s poor track record with IVF. A risky gamble. And totally contrary to the practice of responsible medicine.

  9. I think that the doctor that went ahead with this procedure should be the one to support these children until they turn 18. Why should taxpayers pay for his stupidity?

  10. Pingback: Karey Harwood: IVF Kids: Are They Really All Right? | UNC Press Blog

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