1. “Octomom”: Ethical Problems in the Nadya Suleman Case Jan Hare, Ph.D. Human Development and Family Studies Dept.

2. 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.

3. 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

4. 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

5. 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

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

7. Day 5

8. Guidelines pertaining to embryo transfer <3535-3738-40>40 Cleaving Embryos 1-2235 Blastocysts 1223

9. 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.

10. 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

11. 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

12. 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

13. West Coast IVF Clinic Michael Kamrava

14. Questions fall into 3 categories  Role of Reproductive Endocrinologists  Distributive Justice  Regulation of ART

15. 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?

16. 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?

17. In her own voice Nadya Suleman interview with Ann Curry

18. 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?

19. Arguments Adoption standard should be applied to fertility treatments. Hijacking health care $ by irresponsible decisions

20. 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.