February 15, 2009


I subscribe to a fabulous listserv for pediatric bioethicists. We've been having a spirited discussion of the ethics of the recent octuplet birth.

It's an ethical stew. It's easy to see that this mom is, in my opinion, psychologically troubled, likely with narcissistic personality disorder or another personality disorder which prevents her from getting a realistic grasp on the implications of her actions. What many people see, including me, is that there's a real risk that many or all of her children will end up in the care of the state, and that her given rationalization--that she will finish school and support her 14 kids working as a childcare expert, sounds frankly delusional. Meanwhile, she'll user her school loans to support her family. I have to think this is against the rules for school loans, and besides, it shows a serious disconnect with what this childcare is really going to cost.

That said, the professional ethicists seem to be struggling on certain issues.

  1. Access to care issues. There's a lot of discussion about the woman's rights and the physician NOT having the right to deny a procedure to her that he would do for someone else. This is an understandable slippery slope. If doctors get to decide who is fit to have a procedure, it is easy to imagine all kinds of discriminations coming into play--race, influence, and money, just to name a few. Should doctors have the power to decide who benefits from their skill and who doesn't? With assisted reproductive technology (ART), should it only be for the rich? For the poor and infertile, should they be limited to adoption? That doesn't sound fair. If we think access to ART should be needs-blind, how many tries? Many attempts can cost $100,000 or more. Should the public pay for that?
  2. What is the doctor's role in this? Is the physician simply a nonjudgmental technician, performing a task for which he is contracted? Does a doctor leave his or her common-sense at the door and simply work for the patient? (There seem to be some other relationships like this. Lawyers, I think, have well-defined situations in which they have to do what the client requests even if it's not a great idea.) At some point, this doctor made a decision to go ahead with this for reasons, which are obscure at the moment, that must have included monetary compensation and public relations for his own gain. It would be hard to conceive of the doctor's thought process resulting in a conclusion that the patient would be better off after the procedure. In general, doctors are guided by the Hippocratic concept of primum non nocere (above all do no harm) (it may not be from Hippocrates, by the way, it might be from 17th century doctor Thomas Sydenham, who might also be the first doctor actually to state that doctors should always do what's best for the patient). It's not really clear if helping her get 8 children incremental to her extant 6 is truly acting in her best interest, even if she says it is. Clearly, the doctor has a lot to answer for here.
  3. If a patient came in to a doctor's office, and asked for disfiguring surgery, should the doctor do it? Even if the patient offered a substantial fee in cash? Every doctor makes these kind of judgements to some extent or another. Even in my practice, people come in and ask for a specific treatment, such as antibiotics. But if it's not the right thing for them, I refuse. (I try to be polite about it!)
  4. Who's the patient? This is often a problem with ART/IVF cases. On the one hand, the fertility doctor in this case seems to have acted on the belief that his patient is the woman. While reasonable enough, the result of his work was the birth of 8 more patients. Who looked out for their best interest? Our society generally assumes that the interests of a mother and her unborn child are the same. Cases like this one might call that assumption into question. A woman goes to a doctor, asks for a procedure. Clearly, she's the patient. But at some point that gets complicated when the 8 babies come along, and then they become patients too (notably, they are not patients of the IVF doctor). As doctors, we're required to report parents to Child Protection when we suspect possible neglect of children. In this case, we may have invented a scenario in which a doctor facilitated the mother doing something which will almost certainly result in neglect of some sort. Shouldn't somebody besides this delusional mother be looking out for the well-being of these babies? They are the only innocents here.
  5. Who looks out for society? While happy to acknowledge that the children's welfare is paramount, the cost of caring for this family will be millions. It'll be well over a million even before they leave the hospital. Will we donate to enable the disturbed fantasy of this troubled woman? Or will we simply pay for her insanity out of tax dollars? Should the cost of this whole issue even be discussed as an ethical problem? In bioethics, there's a frequent topic of allocation of scarce resources. If we're all in a lifeboat together, should somebody get more than their equal share of water? What if healthcare resources are limited (as they seem to be)? Should such a disproportionate share be allocated to this one person? [There are many ways to analyze this issue, but here's a really thorough discussion, from the Veteran's Administration--warning: it reads like a good bioethics textbook.]
My opinion: This is very sad on many levels. Those children are struggling now and will struggle their whole lives. No matter how liberal or conservative you are, every child needs the undivided attention and affection of a parent. It's hard to see how these children will get this basic need unless they are placed in multiple adoptive homes. Believing what I just said, the doctor who made this happen has a lot to answer for. When I trained in Utah, there were many very big families. Mostly, they had the stability and longevity to find a way to make a big family work. The level of psychopathology in this mother should have been obvious and have induced grave reservations in any health professional contemplating assisting her in realizing her delusions.

1 comment:

  1. Well said, Dr. wolffe. And some interesting questions to ponder. What about the fame (and possible fortune) she'll now receive from creating such a spectacle of herself. The public loves real-life dramas and tragedies, and this is an ethical and moral tragedy, if ever I've seen one. Given her irrational mental state, I wouldn't be surprised if her decision to birth 8 children was influenced by external motivators and not her heart.

    One thing is for sure: I certainly picked a pediatrician to care for my children who has a respectable ethical conscience! Thanks, Dr. Wolffe! We'll see you soon.


Please let me know what you think. Do you know a child or situation like this?