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EightFourteen is enough

As the Guardian reports, what started out as the more usual happy, wonder-of-modern medicine story of octuplets born in California has turned a little bit sour. It turns out that the 33 year old single mother of the eight newborns who lives with her parents, has six children already, the eldest of whom is seven. That’s 14 children below the age of eight. The story gets more difficult. Apparently, the mother is a self described ‘professional student’ who lives on “education grants and her parents’ money” and plans on becoming a “television childcare expert.” Further, the woman’s parents have recently filed for bankruptcy and her mother has previously consulted a psychologist about her daughter’s obsession with children.

On the face of it (and judging by some of the blog responses) this situation seems ethically problematic. Various medical professionals have made some attempt to shift blame away from the clinicians involved by suggesting that in the end it must be the woman’s choice. Others have cited comment and guidance from the American Society for Reproductive Medicine which suggests that no more than two embryos should be transferred in woman under 35. It appears to be unclear at this point whether the octuplets are a result of fertility drugs or implantation. It is likely that medical assistance of some form was required.

Arthur Caplan in an interview with NPR seems to cover most of the ethical bases in this matter. He points out that there is a significant chance that some of the eight children will be severely disabled. Others have pointed to how difficult it will be for a single mother with limited resources to adequately look after 14 children. These considerations suggest that what is wrong here involves the harm done to these children. However Parfit’s non-identity problem gets in the way of a straightforward application of welfare concerns in this case. That is, we cannot object to the ethical acceptability of having octuplets in this situation on the grounds of the welfare of the resultant children, because these children would not have existed if things had been otherwise.

Caplan also suggests that the clinicians involved in facilitating these megamultiple pregnancies need to take a more prescriptive role. Given the risks to mother and children, it is not enough, he suggests, to take a value neutral stance and to allow the prospective parent(s) to decide. For Caplan, the advice of clinicians should be like that given to serious smokers: “They don’t just say, ‘You got to decide,’ they say, ‘You gotta stop.’” This, of course, runs up against the familiar problem of paternalism and freedom of choice. At what point is it appropriate to attempt to manipulate the freely made choices of competent adults? Of course in the smoking case, the smoker may well continue in spite of the clinicians appeal but the directed recommendation is clearly designed to be an interference of some kind, an attempted imposition of one person’s values on another.

Caplan’s final concern involves costs: “You are going to have millions of dollars spent keeping these babies in the neonatal ICU. It’s either going to show up in the insurance premium or the Medicare budget of the state. And we can go further and say there is a huge financial cost trying to raise eight babies all at once.” Now I have no objection to resource based concerns but I do wonder whether this gets to the heart of the problem of what concerns us about the California octuplets. The costs involved in all that is involved in bringing these children into existence may well tell in favour of a general policy like the guidance recommended by the ASRM (or even something stronger) but I doubt that they can deal with the particular case.

I suspect in all of this that there is a deeper question about what it is to make responsible reproductive (or pre-parenting) decisions. In that case, the criticism is laid squarely at the feet of the mother of eight, not because of the way in which it will affect her children, but because being a good parent (or prospective parent) requires certain kinds of behaviour. The trouble with this, as with the worries about Caplan’s second concern, is that it requires society, in one way or another, to judge and to interfere with the exercise of freedoms and values that are protected tenets of liberalism.

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6 Comment on this post

  1. “Parfit’s non-identity problem gets in the way of a straightforward application of welfare concerns in this case. That is, we cannot object to the ethical acceptability of having octuplets in this situation on the grounds of the welfare of the resultant children, because these children would not have existed if things had been otherwise.”

    Actually, the non-identity problem would merely preclude the children themselves from objecting to the procedure having been done. If the procedure hadn’t been performed, they would not exist, so they cannot be harmed by the thing on which their existence depends. But it doesn’t prevent us from objecting, since we don’t need to be committed to the particular identities of possible children. We can claim that it would be better overall if fewer high-risk, high-resource children were born, that is, that these children were not born.

  2. I don’t think you can have a meaningful discussion about the ethics in this case without considering why it is that quite a few unstable individuals have gone to the extreme of what is generally considered to be a “normal” and even “optimal” choice for women: wanting to be a mother. Unfortunately, as we’ve seen in a lot of adoption, foster, surrogate, and insemination cases, the question so often comes: at what cost? Those costs being to the children and society as a whole, as well as individual women’s psyches.

    Are we as a society pushing too hard the concept that a woman’s premiere value lies in her motherhood?

  3. Hi Mikem,
    Thanks for your comment. You are certainly right about the overall welfare point. That is, if there were fewer high-risk, high resource children born it is likely that overall welfare would be higher. This is effectively the resources point. My point though was directed at concerns about the welfare of these particular children. It seems tempting to say that these individual children have been harmed by being born in this way into this situation – and that is what is wrong in this case. This is where the non-identity problem comes in. As I understand it, there’s nothing in the argument that restricts it to being made by the victims of the harm (though putting it in these terms is a particularly instructive way to demonstrate the logic of the problem). So the point is about the harm done, through being born, to these children. Parfit’s point is that doing otherwise and so avoiding the harm would result in different individuals, not these individuals, unharmed.

  4. Thanks Jennifer,
    I certainly don’t want to suggest that it all comes down to cost and it’s certainly not just about women and their choices. This is part of what I was trying to get at in talking about questions of responsible choices on the part of parents and prospective parents.

  5. I think that I understand your follow-up point to Mikem, Mark, because I am part of a group of people who represent an almost identical problem.

    Adoptees in the US are regularly told that we should be “grateful that we weren’t aborted”. We were “chosen” (almost always untrue; when your name gets to the top of the waiting list, you get the next available kid….and therefore “special” and “fortunate”and our adopters are our “saviors”.

    Yet the rate of psychological distress is several multiples’ higher than among non-adoptees. The rate of physical, sexual and emotional abuse by family members is also higher. The “primal wound” (described in a book of the same name) of losing one’s entire family at birth or shortly thereafter is not allowed to be acknowledged. All records that would provide factual information about medical, genetic or personal history are sealed forever.

    Whenever adult adoptees say that we shouldn’t have been born at all rather than go through the pain of being adopteees, we are called “bitter”. We “must have had a bad experience” but we shouldn’t complain because there’s nothing wrong with the adoption industry as it currently functions in our country. We’re even told to go kill ourselves “if we really mean it”.

    People cannot accept that a human being can look at a situation as a whole and make a statement like “I shouldn’t have been born” but not immediately shoot themselves dead in response. And yet, ethically, it’s the right statement to make. We’re here, so we’ve got to make the most of it, but we recognize that ethically it is not right to force women to go through unwanted pregnancies and then let strangers take the resulting baby away.

    I’ll bet a lot of babies who manage to live to adulthood with a functioning brain after having been born prematurely thanks to extreme multiple gestation will have similar issues. They won’t all kill themselves, but they’ll recognize that the lesser evil would be to not have been born at all.

  6. Mark,

    it is worth noting that the standard non-identity problem does not apply to these sort of cases of artificial reproduction. Some of the octuplets may have been harmed by the decision that led to 8 rather than 1 or 2 fetuses.
    We don’t know the details, but imagine first that multiple embryos have been created. Then the decision is made to implant 8. The counterfactual is that 2 of those same embryos are implanted instead. And those 2 embryos have a much higher chance of death, prematurity and impairment if they are implanted with 6 others. So 2 of the eight might claim to have been harmed. (But the interesting problem is that we would not know which 2!)

    Alternatively, if (as seems more likely), this is a mishap of ovarian stimulation drugs, the case becomes more speculative. 8 eggs are released instead of just one. Would it have been 8 different eggs, or the same egg, and 7 extras? And if the latter, would a different sperm have combined with the egg. There is at least the possibility that one of the 8 could have been harmed by the ovarian over-stimulation.

    Finally, if a decision was made not to perform fetal reduction (selective termination of some of the fertilised embryos), then those embryos that would not have been so terminated have been harmed by that decision. They have a much higher risk of death, prematurity etc as a result. But again we might ask – which of the 8 are they?

    Such cases provide an interesting challenge for those who believe that the non-identity problem is important. If we think that cases where an individual is harmed are problematic, but cases where noone is harmed are not (necessarily), what should we make of cases where non-identity may or may not apply, or applies to some but not all (and we can’t decide which ones)?


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