What does the case of the California woman whose womb carried eight implanted embryos have to do with veterinary medicine? Only that the ethical slippery slope is steeper in our sister profession when it begins to approximate ours.
Implanting eight embryos into a woman following in vitro fertilization is not even remotely defensible if you ask most bioethicists. Where does the woman’s psych profile fit into this case? What was the doctor who implanted the eight embryos thinking? And where’s the Board of Medicine? What does the Department of Health have to say?
Sure, we don’t know all the details of this case (and I’m not sure I really need to based on the superficial details), but someone clearly let this woman have at least eight chances to add to her brood of six children with a litter of babies that will almost certainly never lead normal healthy lives.
I’m not saying we should place limits on the number of children a woman can have. I’m not even decrying any woman's unwillingness to terminate some of her offspring once they were existent in utero. But granting the possibility of survival of more than three embryos in a human is a nasty thing to do to anyone--mother or child(ren). And a medical provider is responsible for this outcome?
Primum non nocere
First do no harm. That means that no medical provider should knowingly contribute to the cruel fate of shockingly premature birth and a lifetime of healthcare concerns (should the infants survive).
Even if a woman (and her family) understands every detail of what may come, there’s no excuse for a physician to allow her to assume this risk on behalf of others. After all, she’s not the one who will have to live in an incubator, undergo multiple surgeries and suffer a lifetime of developmental difficulties. And yet we too often treat infertility medicine from the standpoint of a woman’s right to choose whatever she likes on behalf of her unborn...even before they’re conceived.
Don’t get me wrong, I believe in a woman’s right to terminate her pregnancy under certain circumstances, but I do not subscribe to the belief that medicine should be offered up Burger King-style to anyone willing to pay, much less to a human version of a “collector” (one who hoards pets addictively).
Have it your way?
The physician gatekeeper in this case was obviously asleep at the switch...or worse, this person gave in to the concept of medical care as a “have-it-your-way” commodity:
- She wants a tubal ligation at age 15?
- He wants his stomach stapled but his diabetes isn’t under control and he can’t quit smoking long enough to make him a decent surgical candidate?
- She wants to buy her way up a liver transplant list but she can’t stop drinking and drugging?
- He’s overweight and he won’t take his meds but he still wants that eye lift?
- She swears her kid’s sick and she begs for the exploratory surgery, but her doc suspects Munchausen’s by proxy.
Sad to say but you can always find a doc to do these procedures, though not always in the country of your choice. In the US, satisfying these consumer elections is typically not doable according to our physicians’ code of ethics. There are channels for the mentally ill who seek unreasonable measures. But if you want to foist your will on your children when it comes to "infertility," it seems you can always find a doc willing to take advantage of your desperation.
The veterinary connection
And how is this in any way related to veterinary medicine? In many ways, though the connection might not be immediately apparent. Consider that we can do almost anything we like on behalf of our animals as long as it’s not considered cruel and inhumane by prevailing standards...and that’s a long list of do’s relative to the don’ts:
- We can cut their tails, remove their claws, cut out their canines, slice their vocal cords, do-up their ears and force them to have as many babies as we like.
- We can allow pet owners to take home pets with broken bones, fluid in their chest, ruptured bladders and paralyzed hind limbs...with no treatment or pain control measures.
- We must often treat suffering patients with a minimum of care because our clients can’t or won’t pay...it’s always their choice.
- When we know our clients are “collectors” we can nonetheless continue to allow our clients to take on more and more animals we know are living under increasingly desperate conditions.
- Should we suspect animal cruelty in any guise, few channels exist for any option save an unsavory co-dependency.
It’s clear we veterinarians serve at the pleasure of our paying clients in ways the human medical profession would never tolerate...at least not in most of the world.
Yet the good news is that veterinary medicine has been approximating the human medical profession for decades. We’re ever so gradually catching up. Specialists, standardized protocols, licensed para-professionals, pet health insurance, doc-in-a-boxes.
OK, so they’re not all great changes and we still have a long way to go (please no lengthy discussions on how far we haven't come), but we are making progress. Maybe that’s why it pains me to see physicians take a page out of the veterinary playbook when it comes to offering Burger King medicine.
Could it be that our professions are not so ethically disparate? That as veterinary medicine begins to resemble human medicine the line between the two will continue to blur? I certainly hope not...not if it means human care will succumb to our staggering inequities and ethical insufficiencies...not for the sake of humaneness as much as for our humanity.
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What's the going rate for these IV proceedures anymore? I had assumed (I guess wrongly) that they were out of the price range of a single, non-working, parent of 6 who was living in her parent's basement. If this baby factory did muster the tens of thousands of dollars necessary to add to her "brood" I can think of 6 things the money would have been better spent on. Namely raising her current children.
Something tells me that the tax payer is going to take a hit on this one and/or we'll be seeing an attempt to commercialize these whelplings to "just help with the bills."
Something tells me that if we stopped offering billboard services and TV shows to these litters, we just might see fewer of them. Until then, expect people who are missing something in their lives (this mother obviously is) to give fame a try by outdoing the last queen bee. Hopefully we've reached the limits of the human body here and we won't be seeing any multiples greater than this.
My cousin interned in an inner city neo-nate unit and the stories she brought back over the holidays were always eye rolling. The utter waste of time, money, and of life that occurs simply because we can keep nearly anything with half a pulse alive for a year or so until infection and deformity finally take their toll doesn't mean we should.
Although the "viable" window on premies has been pushed back weeks and weeks, it seems the "normal" window has not.
Christopher February 3rd, 2009 11:15:41 AM
I think the professions remain ethically disparate. The key difference is that in the case of the woman having 8 kids, the PATIENT is making the choices. In the case of the dog being FORCED to breed over and over, the patient is NOT making choices. Her "owners" are. This all traces back to the mere "property" designation in law. Each one of those regrettable circumstances you cite in vet med would be ameliorated by recognizing animals as having some rights to protection under the law, as more than mere property.
Also, another key difference is that this case is garnering national attention, and an invesgigation is being launched; bioethicists are raising questions, speaking out, there may be some ramifications for the health care providers who seem to have breached standard of care. In vet med, that would never happen.
You might argue that the fetuses were being treated like "puppies" in that they had no choice than to be conceived in a high risk pregnancy. But none of us have a choice about the circumstances of our conception and birth. The mother, however, had choice. Absolute choice. Which pets don't.
Stefani February 3rd, 2009 11:19:34 AM
I heard that the mom is asking Oprah for help - how incredibly rude and selfish can you get. Oh, wait, she already has shown that! What's Oprah, a woman who has shown a lot of compassion for people, supposed to do? Look like a mean, rich youknowwhat, and say "Uh, no?" At least when the poor animals who didn't get asked if they wanted to be born, end up needing taxpayer or private $$ to help them, the jerks who caused their problems don't end up with 15 minutes of fame. If anything, they get 15 minutes of shame - which I would like to see this women get. Instead, she gets lauded by nutballs and will get $$ and products and probably a book deal. The fertility doc and practice that went along with this should be closed and the doc lose his/her license. Just how much will those kids feel loved and wanted when they may get so little of their mother's time when they grow up, considering how much she "loves babies."
KateH February 3rd, 2009 11:36:23 AM
Stefani: Actually, she's no longer the patient--her kids are. And that's why I continue to view it as similar to how we deal in puppymill puppies, etc. They had NO choice...same as the pups.
And, yes, I agree that all of those issues I cite would be MUCH different if we viewed animals as more than property-plus. But the guardianship issue is also fraught with tremendous societal consequences for those who DO seek veterinary care and can't comply. IMO our society is incapable of doing more than enforcing consequences for a broader range of animal cruelty designations. That, too, would alleviate most of these cited issues.
Dr. Patty Khuly February 3rd, 2009 11:53:15 AM
Dr. K, I don't disagree that the "guardianship" issue is fraught with all kinds of inherent contradictions etc. However, some have proposed a type of compromise, if you will:
The concept of "sentient property." Sentient property would be a different kind/class of property. Somethign to consider. See http://www.avma.org/onlnews/javma/sep04/040915j.asp
Stefani February 3rd, 2009 02:15:32 PM
So is it only the high risk circumstances for mother and babies that makes this situation more outrageous than, say, the Dugger family, who I think are on number 18? They are media darlings. www.duggarfamily.com
Stefani February 3rd, 2009 02:17:52 PM
Great blog! I echo Stefani, the first thing I noticed was nation-wide media attention and the second was all the peer-professionals willing to go on record citing the unethical behavior in it all. Would we ever see that involving a pet Doctor? Oh goodness, no! Not even when it has been recorded on tape!
Shameful, it is, and sadly likened to a litter or miller. I've had ONE bitch in my entire life that whelped 8 puppies and it took 2 litters and 2 years apart! And that was enough (work for her and for me!).
Yes, I've seen the animal "hoarder", that starts out with altruism and gets in way too deep; the Munchausen's by proxy (childless & may be coincidental)---but one thing that can and HAS been done; is report to the appropriate authorities, get media attention to the case, and prosecute those individuals that have crossed the line to animal suffering and cruelty. Joe Q. Public will pay a price, but Mary Incahoots, DVM will not!
Barbara A. Albright/New Hampshire life-long resident
Pocket's Story from NH February 3rd, 2009 02:41:56 PM
In the Duggar family's defense, they're at least having them one (or two) at a time... not 8 at a time. I'm not much one for their religious views, but I can respect them: They're letting God decide how many kids they have. The kids are homeschooled, and get very little TV, and "strictly monitored" internet time. Every kid gets love and attention, and goes through their day with an older sibling helping them along. Suposedly. they have no debt, And have several properties they've invested in that provides most of their income. They DO accept non-governemental charity... but really, these people are doing it the right way. If there is a right way, anyway.
Those poor octuplets? They won't be. They'll probably be carted off to public school, and paraded around for all the attention they can glean from the get-go. Maybe the Duggar's are guilty of that too... but I bet just as much that Discovery found out about them and came to them first... not the other way around.
But in all of this? I feel most of those por kids that came BEFORE the octuplets.Colby February 3rd, 2009 04:03:36 PM
In the horse world embryo transfers are becoming increasingly popular. I think it is interesting that some registries are trying to combat this by limiting one foal per mare per year. From my understanding ET are really out of the price range of most BYBers (I talked to one person who spent $30k in total - 9 years ago), so it would be reasonable to assume most would want to be able to register the foals that are born. Unfortunately there sometimes ends up being 3 or 4 unregisterable babies of good stock. Just for others who may not know for a horse to carry more than one foal is incredibly risky to everyone involved. Plus horses have a very long gestation (11 months).
spazzy February 3rd, 2009 04:32:00 PM
Colby good point!One at a time is certainly healthier for all concerned. So there is no health practitioner ethics issue there. As for the sheer numbers, I am not necessarily judging the Duggars, but its really not possible to take good care of 18 children. How do they do it? The older sisters become pseudo-moms. (Yup, I watched the show a coupla times). Is that good for them? I dunno. They will be mature and responsible. They also are missing out on some aspect of childhood.
Would we feel differently -- less judgmental toward this mom -- if the 8 babies had all died?
What if it were 5?
A very intelligent, responsible woman in my workplace -- who already had one daughter -- a couple of years ago gave birth to quintuplets. They all were born alive. They all died within hours of birth. The overwhelming feeling we all felt for her was grief, concern for her feelings, and deep sadness and empathy, not judgment. It really didn't matter how the kids had been conceived. A little over a year later, she gave birth to twins. Healthy. Boy/girl. I think that answers the "how" question. We were very happy for her of course.
Older women who use fertility treatments are often encouraged by the doc to put back more embryos to increase the chances of even one "taking" -- hence the high risk of multiples. I'm sure my coworker believed it highly unlikely she'd end up pregnant with 5, she was probably hoping for 1 or 2. And then when she found that she had high order multiples, she probably simply couldn't do selective reduction -- emotionally.
Maybe we should focus on the issue of enforcing stricter standards on # of embryos implanted with IVF than on judging the woman and her kids. After all, they're here now.
I just notice that we seem to have drawn a "line" somewhere. We've got "John and Kate + 8" with their twins and sextuplets and I've never heard anyone harsh out on them. Where's the line?
Isn't it interesting that the families not being judged harshly for tons-o- kids (John&Kate et al) are 2-parent, but vitriol is being levelled at the single mom?
Stefani February 3rd, 2009 04:35:41 PM
Dr. K, I'm sure you know better than I but, from my perspective, Vets (on average) hold the higher moral ground. My fear is that your profession will slip into the abyss by following the human docs into it. Insurance is not a good thing when it spreads the cost of lousy decisions. "to anyone willing to pay"? Not likely. There's likely to be a $3,000,000+ hospital bill for those babies before they even make it home for the first time. If she has insurance, all the rest of us suck up the cost of her decision by way of increased premiums and the insurance isn't likely to pay the full bill; if she doesn't, the taxpayers will pick up the tab. How many critical life saving procedures could be performed with those funds? Though, real life, limited resource decisions that Vets and pet owners have to face because, well, frankly, because they have to pay the bills.
Stefani, While I would feel grief for the mother's loss, I for one wouldn't feel any differently about the underlying poor decision making involved. However, if some had died, we probably wouldn't be free to have this type of discussion so let's take advantage of that while we can. Drawing the line you speak of isn't easy for pets or humans and it involves many very touchy and sensitive topics to be discussed openly and frankly.
However, we rapidly approaching a time when it will have to be addressed (again, as we do so periodically over decades) because we are being reminded that we live in a world of limited resources. One may have the legal right to procreate (oneself or one's pets) but is it morally acceptable to do so if the offspring will suffer? or if others will suffer or want for basics as a result? Medicine (I suspect human and veterinary) tends to treat what is right before it in critical need or paying at the expense of long term health of those patients, let alone the long term health of society. With the socializing of medicine (through insurance or otherwise), the ethical standards need to address the long term as well as the short term. How long before pet insurance is $300/month/pet?
PJBoosinger February 3rd, 2009 05:24:42 PM
Refering to the comments in the blog about animal hoarders and animal cruelty... I think alot of that comes down to the laws in place to protect the veterinarian or staff, or I should say the lack thereof. Many places do not follow up on complaints figuring that it's just revenge on a non-paying client. Worse many states don't protect the vet/staff privacy. So to report any of them invites criticism by the community and possibility of lost clients/income. Until the laws can provide anomonimity (sp?) and protection to those that file complaints, AND until the agencies involved take the issue seriously with proper funding, nothing is going to change in that regard. JMHO
cl February 3rd, 2009 09:09:56 PM
cl: If you survey the animal cruelty laws in a lot of states, the veterinarian is immune from legal action, reporting suspected cruelty/neglect to the proper authorities and in some states it is a "required" action to do so.
Many states do not 'enforce' laws on the books, very simply because the penalties are so minimal and the court systems are backed up with "more important" cases (not my opinion, just noted facts) and lack resources (money) to prosecute.
That said, I believe it is still important to 'report' and have the information on file, for future prosecution OR perhaps motivate the individual(s) to change their ways if known to be under scrutiny.
Protect the staff & privacy? My goodness, since 95% or more official complaints are dismissed and permanently sealed/shielded from the public's eye, how can one think anything but government/law enforcement protection to the pet medical professionals?
Barbara A. Albright/"Pocket's Story from NH" (to illustrate the above)
Pocket's Story from NH February 3rd, 2009 09:39:38 PM
Hmm, I thought maybe you were mentioning that wom(b)an and veterinary medicine together because she had a litter. Our golden retriever only had six!
Donna February 3rd, 2009 11:11:42 PM
cl, I find the whole concept of authorities being able to act upon anonymous tips to be disturbing. I don't like the concept of authorities being able to invade homes on the basis of "somebody says..." Give tipsters limited protection from suit if they're acting reasonably but don't take away someone's right to confront their accusor or to hold a vindictive accusor responsible. These types of tips are used mostly against the poor who have darned little access to the courts or lawyers to start with. Let's encourage people to stand up for what's right not to do so behind a cloak of anonymity.
PJBoosinger February 4th, 2009 10:07:31 AM
PJBoosinger: I agree! My ppoint is that the "professional" is immune. And obviously, I do behold the reasoning of "anonymity" ever, when stating truths.
In this state it appears that the middle class does not fare much better to affordable legal access, either! Barbara A./NH
Pocket's Story from NH February 4th, 2009 04:50:57 PM
Stefani-
I think it's about more than just the fact that Jon & Kate's kids were born into a two-parent family.
This woman lives with her parents. The family recently filed for bankruptcy. She was unable to provide for the six kids she already had. IMO, she had no business intentionally bringing one more child into that situation, let alone eight. Even if you completely ignore the possible medical repercussions, more kids were the last thing this woman needed right now.
I may not be a fan of Jon & Kate, and I may not necessarily agree with the route the Duggars have taken, but at least in these situations, nobody made the decision to bring children (let alone higher-order multiples) into a home where they were already incapable of providing for the basic needs of the pre-existing kids.
This woman clearly has some serious problems, and I hope she gets them in check for the sake of those kids. I also hope the media and public don't reward her for what she's done. Encouraging this sort of behavior is in nobody's best interest- let alone the children.
Just my thoughts. :)
Ramen Connoisseur February 4th, 2009 06:29:24 PM
re: the Duggars adn John and Kate. don't be so sure that are are able to support those families w/o help. While word has it htat hte Duggars have income from a rental property, but they also have received many gifts, including donated food and appliances from their home makeover special, and they make money off their shows, no doubt. They shop at thrift stores and do their own haircuts. Is that simply admirable, or a sign that they don't have the resources to "provide" on their own?
John of John&Kate previously worked in the software field but no longer does -- he stays at home, thanks to their celebrity. They freely admit that they support their family through sponsorships, speaking engagements, and the TV show. They, also, can't "provide on their own." Or choose not to. They are supported by our "cute multiples" voyeurism.
Hmm, wonder if that has anything to do with motivating others to have high order multiples?
"Miss So and So, Plus 14".
Stefani February 4th, 2009 10:14:28 PM
Barbara, Although professionals aren't always technically immune, as a practical matter, they are generally immune. On that one, I'd need to rail at my own profession and, once I start on that one, it's hard to stop and there simply isn't enough space on here so I'll try not to start. :)
PJBoosinger February 5th, 2009 12:15:54 AM
Stefani, I'm with you on the predecessor multiple births. And the "fame" they got is part of what encourages others like this woman. Who now has a "representative" to speak for her. (I changed the channel but it looked like an attorney doing PR, PUKE!!!)
PJBoosinger February 5th, 2009 12:18:29 AM
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