I love children. I was trained as a children’s doctor. And, I was blessed with three of my own. My heart breaks when patients and friends struggle to build a family and conceive without success. Many choose to attempt adoption, others plow through years of expensive fertility treatments. The brass ring of parenthood, sadly, is often elusive, even with these options.
When fertility treatments are successful, multiple births may increase the risk of medical problems in the babies, short and long term. Survival beyond the perinatal or neonatal period may be accompanied by neurologic and developmental deficits triggered by intrauterine compromise. As a biological parent of a naturally conceived singleton child with undiagnosed oxygen deprivation in utero, I can testify the costs, literally and figuratively, of raising a wonderful little girl with severe disabilities to adulthood. Even with a loyal husband, supportive family, and a reasonable income, the road has been challenging. I cannot begin to imagine the path stretching before a single mother of limited economic means with 14 children, even if her octuplets survive and are fully healthy and without disabilities.
Even with the limited information currently available, I also cannot run from considering the ethics of her situation. There has been an outcry from many fronts that, even excluding her economic realities from the discussion, her decision to engage in fertility treatments with six children age 7 and under at home was misguided. As news of her social circumstances leaks to the media, pundits are decrying her choices to bring more children into the world that she cannot afford, and to welcome these children into an environment that will challenge her parenting skills for all 14 of her offspring. The blogosphere is spicing up the conversation by addressing the mother’s immigration status and the issue of public taxpayer support for fertility treatments and/or child-rearing of multiple sons and daughters.
(Exhales slowly…) My position? “No good deed goes unpunished.” As a socialist and progressive, I have tried to adhere to a philosophy that avoids the “lifeboat” mentality, i.e. the idea that America is a lifeboat on the violent ocean and that we must limit those we allow on the boat so that those of us floating above the waves can survive. I have always felt that the “boat” is big enough for all of us, and that the new passengers we pull aboard will actually help us “row” to an even better environment. What I have learned to date about this case makes me wonder if I might have to address the idea of limits.
Unlike China, the US has always avoided the idea of dictating the numbers of children someone can parent. Families with children by the dozens have populated our cultural milieu (and our libraries) for generations. The concept of limiting reproduction brings echoes of eugenics and ethnic cleansing that terrify progressives and groups that perceive themselves as potential victims. Ethically, should “the government” be involved in reproduction? No. Reproduction should remain a private matter for the individual mother—a private choice.
But, would I have made the same choice as this mother? No. Would I have, as a physician, recommended this road to this mother? No. Would I have sought to bar her from expanding her large family? No.
But, if I had been a fertility specialist, would I have provided pills, embryos, or other treatments to this mother of six young children? No. And if this mother had responded to me (the hypothetical fertility specialist) that selective reduction of embryos implanted was “off the table” for her (due to personal, ethical, or religious reasons), would I implant more than two embryos? No. Ethically. Because as a doctor, I would not want to promote a gestational environment for the fetuses that would be extremely high risk.
Medically, there are limits as to how many multiples can be safely carried in pregnancy. Evolution has guided human reproduction towards one or two babies at a time, in most cases—not just to provide a nurturing pre-birth environment, but to allow a parent to feed and raise a vulnerable infant to a level of independence that can allow for other caregivers in a community to effectively assist if needed. It would, to turn a phrase, take a village of parents to raise a village of children. Fertility experts need to critically evaluate the risks of multiple embryo transplants and adhere to the medical limits of the human body. In vitro fertilization and other fertility treatments have provided many would-be parents with a chance to have a child—we should not use this unusual example as a reason to decry assisted conception and pregnancy in general, i.e. we should not throw out the baby with the bathwater. Clearly, however, we should use evidence-based guidelines as to how many multiples can be safely brought to healthy term in developing protocols and procedures for medically treating infertility. The Practice Committee of the Society for Assisted Reproductive Technology and the Practice
Committee of the American Society for Reproductive Medicine has developed such guidelines. The recommendations for women under age 35: For patients under the age of 35 who have a more favorable prognosis, consideration should be given to transferring only a single embryo. All others in this age group should have no more than 2 embryos (cleavage-stage or blastocyst) transferred in the absence of extraordinary circumstances.
A more challenging question takes us back to the lifeboat. Can we or should we consider setting social limits to reproduction? Our conservative brethren might cheer at this question. They have been advocating anti-choice and anti-contraceptive legislation for years. In their ideal world, families with 14 children might become the norm—but the lack of provisions of child care, economic support, and mental health services in their no-tax society might quickly bring more tragedies like those we have recently heard about in California and Ohio. On the other hand, the slippery slope of reproductive limits could bring us back to the possibility of a China-like one-child policy with the attendant infanticides of females, and overabundance of males. What about other criteria for restrictions? Parental skills, financial capabilities, home environment, etc,…? Theoretically, yes, American parents should be skilled, capable, and have a stable income and home environment. What would we do then with the father who has lost his job and his house—throw him into the parental version of debtors prison? And who would determine these criteria for a “parenting license”? Would cigarette smoking, alcohol or marijuana use, a medically challenging family history, or chronic conditions such as diabetes, asthma, obesity, and hypertension exclude some from being parents? Would a particular ethnicity? Eugenics would once again rear its ugly head.
Then could we simply consider stopping public assistance once parents have exceeded reproductive limits that would strain our society’s economic lifeboat? Theoretically, yes. But then, we would be punishing the children who did not choose to be born into large, poor families. Close their doors to equal opportunity and we might find our “lifeboat” society attacked by very angry outcasts who have nothing to lose.
Obviously, the choices this mother and this family have made to continue a pregnancy with octuplets and to raise 14 children in economically challenging circumstances are an example of one end of the spectrum of choice. Her choices would most definitely not be mine. But this rare exception should not lead us to castigate the scientific advances that have allowed so many parents-to-be to achieve their dreams through medically guided fertility treatments. Nor should it lead us to pull up our gangplanks and barricade ourselves in the lifeboat fortress fearing that our tax dollars are being wasted on the humanitarian effort of providing children with food, a home, and a good education. That investment will still pay off—14 times.