Eight is Enough
by Jeffrey P. Kahn, Ph.D., M.P.H.
Director, Center for Bioethics
University of Minnesota
The recent news of the birth of octuplets in Houston has rekindled discussion of the ethical issues in medically-assisted pregnancies that can result in six, seven and now eight babies. These octuplets, and the birth just over a year ago of the McCaughey septuplets remind us of the power and the responsibility in being able to manipulate reproduction. These amazing technologies can help otherwise infertile women have children, but point out that there can also be too much of a good thing. Should we limit the maximum number of multiple births in a given pregnancy, and if so, how? What are parents' and physicians' responsibilities for making sure that these limits are respected?
The health risks to both pregnant women and babies increase exponentially with additional fetuses. Triplets pose greater risks to mother and children than do single births or twins, and these risks increase greatly with four, five and six fetuses, and so on. The McCaughey septuplets are a story as much for the fact that they represent a medical miracle of survival as for the curiosity we all have in what it takes to feed, diaper and otherwise care for seven infants.
Unlike animals like dogs or cats that have litters, women aren't made to carry such numbers of offspring through the nine months of gestation it takes to go from fertilization to live birth. There just isn't enough room, nutrition, or oxygen to go around for so many fetuses, as the months of bed rest and the tenuous medical courses of the two most recent cases attest.
As the death of one of the Houston octuplets shows, even if all the babies are born alive, they have long odds to overcome. Because they are so underdeveloped, they face the same treatment issues as other premature infants, including long and extremely expensive stays in the intensive care unit (the estimate for the Houston octuplets is $2 million from birth until they leave the hospital), and that is only in the short-term. These children face unpredictable physical, cognitive, and developmental challenges in the longer-term.Medical progress or medical failure?
The truth is that these are health risks that mothers and children should never have to face. Physicians using fertility-enhancing techniques know that fertility drugs can cause many eggs to be ovulated at once. Many or all of those eggs can be fertilized to create the freakish possibility of seven, eight , and more fetuses. The consequence is either extraordinarily risky pregnancies, or the need for horribly difficult decisions about "selective reduction" -- performing abortions to reduce high multiple pregnancies to safer twins or triplets.
But relatively low-tech ultrasound can be used to determine how many eggs are being ovulated by a woman after taking fertility drugs. When it is clear that a large number of eggs are being produced, physicians can and do counsel patients to avoid having unprotected sex until the next cycle, with (hopefully) fewer eggs. With available technology, there is no excuse for unexpected cases of high multiple pregnancies, and when they do occur it should be viewed as a failure of medical care rather than a success of reproductive technology.
The need for responsible reproduction
Couples need to agree to abstain from unprotected sex when the risks are high, or to consider the option of selected reduction. Some have suggested that this agreement be part of the informed consent process required of women before they undergo treatment with fertility drugs. We must question the medical care provided by physicians who allow octuplet pregnancies to occur, and the judgment of prospective parents who are willing to take such high-stakes gambles with the lives and health of their offspring. The risk of harm to mothers and children must be weighed against extremely long odds that such pregnancies will end with thriving babies.
The natural occurrence of high multiple-birth pregnancies is rare, but technologies for assisting reproduction have made them more common. It is this foreseeability that makes them preventable; and as in other aspects of life, if we don't learn from our failures we are destined to repeat them.
"Ethics Matters" Archive
where you'll find other columns from Jeffrey Kahn
on a wide range of bioethics topics.
Center for Bioethics and CNN Interactive.
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