The Ethics of Octuplets

Fertility clinics are round-the-clock operations, with women coming and going seven days a week for estrogen-monitoring and egg retrieval. The weekend after a California woman gave birth to octuplets, traffic was steady at the Duke Fertility Center in Durham, N.C. Susannah Copland, who oversees Duke’s in vitro fertilization (IVF) program, was on call and noticed that “everyone was buzzing about the octuplets.” Some patients were shocked, others unnerved. “I don’t want eight babies,” they told her. “And we don’t want you to have eight babies,” she responded.

How Nadya Suleman, 33, became pregnant with octuplets is the subject of rampant speculation. Her mother has indicated that the preemies are the result of IVF treatment, a confounding thought from both a parent’s perspective–Suleman already has six children under the age of 8–and a physician’s. In June, just about the time those eight babies began growing inside her womb, the American Society for Reproductive Medicine (ASRM) issued updated guidelines on the number of embryos that should be transferred to a woman’s body in the hope they’ll implant in the uterus and lead to a live birth. Women under 35 should transfer no more than two embryos, down from the maximum of three recommended in 1998, and women over 40 should attempt no more than five. (See the top 10 medical breakthroughs of 2008.)

These are guidelines, however, not laws. And until Suleman discloses how the octuplets came to be (via fertility drugs? IVF? embryos splitting into multiples in utero?), the mere possibility of a doctor’s transferring a large number of embryos to a relatively young patient–an unmarried mom raising four singletons and a set of twins–has put fertility specialists on the defensive as they try to counter the perception that theirs is an undisciplined, irresponsible profession. “The word cowboys comes to mind,” says Robert Stillman, medical director at Shady Grove Fertility Center in Rockville, Md., the country’s largest fertility clinic.

But he and other fertility doctors contend that reproductive medicine is among the most regulated specialties in the U.S. Clinics have to report to the Centers for Disease Control and Prevention the number of embryos transferred in each IVF cycle–in which sperm and egg are fertilized outside a woman’s body then transferred to her uterus–as well as the resulting number of live births. This reporting system was set up to help potential patients assess their chances of having a baby but has evolved into a way to monitor a clinic’s number of triplets and higher multiples, who are more likely to have serious health problems.

As IVF success rates have increased, the average number of embryos transferred has gone down, from 3.9 in 1996 to 2.4 in 2005. Single-embryo transfers are now recommended in many cases; generally, the younger the patient, the likelier it is that an embryo will implant. A recent article in the journal Fertility and Sterility even suggested recasting how fertility clinics view outcomes: a singleton birth should be considered a success, triplets a failure.

See the top 10 scientific discoveries of 2008.

See pictures from an X-Ray studio.

In the U.S., where one IVF cycle can cost upwards of $12,000, women who have to pay out of pocket may not be able to afford to try and try again. And if physicians are pushed to transfer more embryos? “Doctors’ attorneys are advising them, ‘You have to do it,'” says ASRM spokesman Sean Tipton. “The courts have made clear that decisions about what to do with embryos are in the hands of patients, not in the hands of physicians.”

If moms of multiples were to approach Stillman for more reproductive assistance, he says, he’d be obligated to help. “As a parent of two kids, I may think they’re crazy, but I’d tell them what I always tell patients: Our goal here is as many children as you want, but preferably one at a time.” (Read “The Year in Medicine 2008: From A to Z.”)

Arthur Caplan, a medical-ethics expert at the University of Pennsylvania, takes issue with that stance. It’s O.K. for doctors to say no, he says; they do it all the time. Some surgeons, for example, won’t insert breast implants in women under 18. “Medicine is not a restaurant, and doctors are not waiters,” Caplan says. “They don’t take orders from patients.”

Some fertility specialists worry that Suleman’s octuplets–only the second set in U.S. history–will lead to calls for a system like the one in England, where reproductive medicine is overseen by a government agency that can revoke a doctor’s license or close a clinic and sets age limits for fertility treatments. “Would we write laws limiting the size of someone’s family to six?” asks Richard Paulson, director of the fertility program at the University of Southern California. “Would we write laws mandating selective reduction?” he asks, referring to the option of aborting some embryos if a high number of them successfully implant in the uterus.

The answer may partly depend on Suleman. She has yet to divulge who helped her get pregnant with the octuplets. But she has hired a p.r. firm and is rumored to be weighing seven-figure offers for her first televised interview. Her publicist, Joann Killeen, told reporters, “As soon as she’s able, she will tell her story, and it’s an amazing story.” Doctors, moms and ethicists are all ears.

See 9 kid foods to avoid.

See pictures of what makes you eat more food.