Ethical issues in Reproductive Medicine: Octuplet Edition

There was a really good article in the Philadelphia Inquirer by Arthur Caplan, a bioethicist whom I sometimes disagree with, but always respect and enjoy reading, discussing the set of octuplets recently born to Nadya Suleman. Ms. Suleman, who apparently is unlikely to be able to adequately support the children and already had 6 other kids, received in vitro fertilization in order to have more children.

Caplan argues persuasively that something went wrong here, but I want to address a few areas where I disagree with him, or at least with how his argument is presented.

The most obvious questions raised by this sad saga include: How did Nadya Suleman become a fertility patient? And how did she get eight embryos implanted when she already had six young children to care for in a tiny house, with no partner and no income?

Some fertility doctors would answer that it's not their job to decide how many children a person can have. Jeffrey Steinberg, medical director of the Fertility Institutes, which has clinics in Los Angeles, Las Vegas and New York City, was quoted as saying: "Who am I to say that six is the limit? There are people who like to have big families."

James Grifo, a renowned fertility specialist at New York University, had little time for those wondering why Suleman was a patient. "I don't think it's our job to tell them how many babies they're allowed to have," he reportedly said. "I am not a policeman for reproduction in the United States."

With all due respect, the idea that doctors should not set limits on who can use reproductive technology to make babies is ethically bonkers.

I agree with his assessment that doctors should set limits on who can use reproductive technology. That said, Dr. Steinberg is correct that "there are people who like to have big families", and in many, and probably most, cases physicians should be willing to help them. Dr. Grifo is also right that he is "not a policeman for reproduction." But neither of those quotes really explain why a doctor should choose to help this particular woman have more children. While there are many people who could successfully raise extremely large families, it seems unlikely that Ms. Suleman is one of them. One does not have to police reproduction to think about what is in the best interest of the patient. People often want something that is not best for them, or their family, such as Ms. Suleman's other 6 children who are already fighting for limited resources.

If the doctor facilitating this procedure knows the patient cannot care for the children, they are not just doing harm to the patients family, but are, in essence, helping to steal from society as a whole. Further in the article, Caplan writes:

The other major ethical problem raised by this story is the hijacking of health-care dollars by someone acting irresponsibly.

Suleman had to know that starting a pregnancy that might create eight tiny lives was to risk killing herself, as well as killing or severely disabling one or more of the babies. Fortunately, she made it through the pregnancy. But the cost of neonatal care for her eight new children probably will exceed $1 million.

When they are discharged from intensive care, more millions of dollars in medical costs likely await, not to mention the help Suleman will need just to handle all of her children's basic needs.

Again, I agree with the general thrust of Caplan's argument. Taxpayers or insurance companies should not have to pay for the health-care costs that Suleman voluntarily creates. It's crazy. My only objection is to the implications regarding starting such a pregnancy that might be a risk to disabling one or more of the babies. It's certainly an accurate description, but I am not entirely sure I want to say that it would be better for the child not to be born at all than to be born disabled. That is a far more complex issue. It is still certainly objectionable in terms of Suleman's inability to care for the children, especially if one was disabled. If that is what Caplan means, than I agree with him completely.

Then, sadly, he has to bring regulation into it:

If the medical profession is unwilling or unable to police its own, then government needs to get involved. We already have rules governing who can get involved with adoption and foster care. Shouldn't these minimal requirements be extended to fertility treatment? And shouldn't some limit be set on how many embryos can be implanted at one time...

I am not sure whether or not government needs to get involved. I certainly agree that physicians must take ethical responsibility in terms of deciding who to provide treatment to, but if they fail in some extreme cases, such as this one, does that mean that regulation is the answer? I think it is generally a bad idea to make public policy decisions based on extreme cases. Not only do they tend to cloud or decision making with our emotional responses, they often are, truly, exceptions to the rule, and as such laws and regulations designed to address them tend to work poorly.

But, if we were to invoke government involvement, what would the cost of regulations be?

Would we allow only a certain amount of children per family? If so, that discriminates against those would-be parents that can support a large family. Would we decide that only those who can afford children have the right to care? That seems more reasonable. Of course, it is also a bit hypocritical in a society where welfare regulations economically encourage the poor to have more children naturally. There is a difference between allowing people to have children and helping them to, as an individual actor, but in terms of public policy I think it is less clear. The lawmakers are not helping or allowing parents to have children, but instead allowing them to have children naturally and allowing them to have children with a medical intervention or just allowing them to have children naturally.

Further, would the regulations hurt families that wish to have more children (and are capable of supporting them)? It is almost unheard of for regulations to not affect innocent bystanders, if only by the cost in time and effort to prove they can support more children. Are these costs greater than the cost of allowing the seemingly rare outliers like Ms. Suleman to have children? This has not been adequately addressed in order to determine if government involvement is appropriate.

On the other hand, I see very little harm in reducing the amount of embryos that can be implanted at one time, assuming there is no evidence of some advantage to having children that way.

It's worth reading the whole article, Caplan is a great thinker and enjoyable writer.

And in related autism and vaccine news

CNN reports that the special vaccine court has ruled that autism isn't caused by vaccines, sortof.

A special court ruled Thursday that parents of autistic children are not entitled to compensation in their contention that certain vaccines caused autism in their children.

"I must decide this case not on sentiment, but by analyzing the evidence," one of the "special masters" hearing the case said in denying the families' claims, ruling that the families had not presented sufficient evidence to prove their allegations.

While I feel badly for the parents, most of whom probably believe that the vaccinations caused their childrens' autism, this sort of ruling is a good step. Judicial rulings should never be seen as settling any scientific question, but when there is very little evidence that vaccines cause autism the court should be ruling on the side of the scientific consensus.

While it may be valuable for scientists to continue to investigate all avenues to determine the factors leading to autism, including vaccines, any public, realistic response that weakens the relationship between the two in the public eye is probably a step in the right direction.

In Your Face, RFK Jr!

And Jenny McCarthy, among the seemingly vast hordes of people who think, despite all the evidence, that vaccines cause autism.

As per the Sunday Times

THE doctor who sparked the scare over the safety of the MMR vaccine for children changed and misreported results in his research, creating the appearance of a possible link with autism, a Sunday Times investigation has found.

Confidential medical documents and interviews with witnesses have established that Andrew Wakefield manipulated patients’ data, which triggered fears that the MMR triple vaccine to protect against measles, mumps and rubella was linked to the condition.

When I have been close to a scientific news article, or I when I am very familiar with the research, I notice mistakes and overstatements in much of the popular reporting. Since this matches up with most of the scientific consensus, though, I am inclined to give it the benefit of the doubt.

With any luck, this will help to further discredit the idea for parents who are looking for any possible treatment for autism, since that tends to go hand in hand with pseudoscientific woo. And, hopefully, it will make people less distrustful of vaccinations, which have so many benefits.

It is hard to measure the harm that something like this has caused, as it is not even responsible for many people's fear of vaccination, but certainly a step towards truth will help.

Governor Paterson's Soda Tax

Governor Paterson of New York has proposed an increased tax on non-diet soft drinks for two reasons: to increase state income in the face of a budgetary shortfall and to help combat obesity. I think the tax is incredibly misguided for a few reasons.

I am not a fan of "sin" taxes, taxes specifically focused on eliminating or reducing something society dislikes. It's certainly better that we overly tax cigarettes and soda than banning them. By just taxing them more heavily, the effect on consumer liberty is far less constrained. I lose the freedom of buying soda without interference, but I still can get the soda I want. But I find the whole idea of trying to dissuade people from buying something, and punishing them if they do, to be an inappropriate and largely unjust way of funding necessary state programs.

That said, let's get into the specifics of why the soda tax is a bad idea. The soda tax is supposed to do two things: decrease obesity and increase revenue. Obesity should come first, since the tax is proposed as a public health measure.

As I, and many others, can attest to, it's plenty easy to be obese without drinking any sugary soda. The impact of one item, such as soda, is unlikely to have a large effect on obesity. Obesity is complex: it is the product of an interrelation between genetics, consumption and lifestyle. Assuming this program worked to remove all the calories people get from non-diet soda (which would only be plausible if soda were to be banned) the effect is not entirely predictable, and probably would not be especially great.

Is it even better to drink diet soda than non-diet soda? I certainly think so. I probably consume somewhere from 2 to 4 cans of diet soda a day. The evidence is mixed, however. Studies have shown weight loss in those that switch to diet soda, but others have shown no change, or weight gain. The results are not yet in as to whether soda with non-caloric sweeteners like aspartame are better for those trying to lose weight than soda with sugar or high-fructose corn syrup. When I tried the Atkin's diet a few years ago, they advised dieters to avoid both diet and regular soda, because diet soda had been linked to slower weight loss (and of course regular soda is high in sugar). From my understanding of the literature, it seems most likely that if dieters are actively counting calories (or something similar, like Weight Watchers points) diet soda might be helpful, but for the average person, diet soda may lead to an increase in consumption of other calories that partially ameliorates the effects of avoiding those in the soda. Since this tax is not directed at conscious dieters, but rather at those who are not making rational consumption choices, the public health effect is likely to be little.

Will the tax decrease consumption? The tax is not very large, but it may have an effect on consumption. However, as a relatively small tax on a preferred food (which is, for those that want energy, better than the alternative) is likely to meet relatively inelastic demand. Let's compare this to another similar tax I mentioned earlier, the cigarette tax. In America, while cigarette taxes have increased, demand has fallen. There is some evidence that these phenomena are related (especially in dissuading teenagers from starting smoking), but most of the effect is likely due to the changing societal view of smoking. In many parts of western Europe where taxes are many times higher than ours on cigarettes, smoking is far more popular. Smoking's popularity seems to be far more correlated with the way our respective societies view smoking than the cost of cigarettes.

Will the tax bring in more state money? It seems unlikely to drastically negatively impact consumption, so probably. Is it a good way to bring in money? I certainly don't think so.

Again like cigarette taxes, most obesity taxes are likely to be regressive, most painfully affecting the poorer members of the community. Even in his CNN editorial, Governor Paterson said:

Nearly one out of every four New Yorkers under the age of 18 is obese. In many high-poverty areas, the rate is closer to one out of three.

The demand for less healthy, calories dense food tends to be higher among the poor. Is it really appropriate to increase their tax burden to make up for a budget shortfall? Some might argue that the poor people can make the rational choice to avoid the slightly more expensive foods (and many probably do), but it's interesting that to be defending this tax on those grounds, you also have to deny that they can make the rational choice to avoid less healthy foods to begin with (and many probably do, too).

When trying to figure out if something is a good idea or not, I attempt to consider all the possible effects. This measure decreases economic liberty, and by singling out one industry, if it decreases demand it is doing so in a targetted way, instead of decreasing demand for all unhealthy food, which seems like it is likely to have a greater negative effect overall (I can bump into a few people on the subway lightly and still have done less harm than bumping into another person as hard as I did to the first three added together). The effect on people's health could be a mild improvement, nonexistent, or possibly even a decrease (depending on the effects of aspartame on total caloric intake). The measure is also may negatively impact (financially) those who need their money the most. Does it sound like a good idea to you?

Cognitive Errors: The Availability Heuristic and You

Cognitive errors is an aggregate term I use for biases in cognition, biases in memory, and fallacious logic. Cognitive errors are almost always interesting, and often illuminating. It's amazing how often they are incorporated into our everyday understanding of the world, from subtly affecting our opinions to blatantly causing them.

Some of these cognitive slip-ups can be harmless, some have horrible consequences, but most are somewhere in between. There are two main reasons for us to consider them, when discussing ethics (besides their presence just making stories more interesting). Cognitive errors affect how we act; if we are attempting an action in order to help others, we want to make sure what we are doing is actually the most helpful action. This aspect is similar to the law of unintended consequences: we really want to make sure what we are doing actually is a positive thing. The other main, albeit slightly overlapping, reason to consider these errors is to temper our judgments of others: the effects and intentions of another person's actions can be opposites.

Our first cognitive error is the availability heuristic.

The availability heuristic is basically the error we make when we assume that because something is more mentally available it is more likely. What make's something available, you might ask. Two major factors, which also influence each other, are the amount of attention that is naturally drawn to something (it's salience) and the amount we are exposed to it. Let's compare car and plane crashes. Car crashes are far more likely to kill us (since we are more likely to be in a fatal accident), but many people think of flying as more dangerous. An airplane crash is more salient to us than a car crash. When worrying about a car crash, we may think of it as a quick accident, whereas when we think of an airplane crash, we may be drawn into thinking about falling out of control with people panicking around us, and the longer time-frame of such a crash. Perhaps partially because of this, plane crashes generally get more focus in the news than car accidents, thus further increasing its availability. Since most of the time we don't logically compute the differences in risks, we are often easily fooled by availability of information.

There are many ways this relates to living a good life. If you wish to make a difference in the world, you may well be fooled into over-concentrating effort in one direction when you could do far more in another. A (fairly) recent example would be the tsunami in southern Asia. There was an outpouring of support to help provide disaster relief. The tsunami was covered widely in the media and was, apparently, a particularly salient event. However, other less salient and covered problems like those occurring in Darfur or Sudan which needed more help did not get it. The availability heuristic helps us fail when we try to help. (Luckily, relief groups like Doctors Without Borders limited the amount they would spend in one area to try to divert more help where it is needed.)

It also relates directly to how we decide what to do. Our naive understanding of outcomes is directly influenced by the availability heuristic as well. Some salient negative effects of a policy or decision can obscure much greater, but less obvious, positive effects.

It's always something to try to think around when making decisions or trying to understand the world.

On Living A Good Life (or Stand Back! I'm Going to Try Science!)

This blog is devoted to philosophy and science. New discoveries and applications in science often lead to interesting new ethical questions and they also often lead to an interesting philosophical discussion of what the results mean. But the area that most interests me (and the reason this blog is titled the Ethics of Everything) is in the application of scientific advances and discussions to living a good life.

My view on personal ethics is a form of utilitarianism. While there are many types, utilitarians basically argue that something is good if it has good results. I describe my personal view as natural rights utilitarianism (there is probably another person who has posited this previously with a better name. There generally is). This form of utilitarianism argues that when calculating utility (the goodness of results) we must also include things like life, liberty, and property along with happiness. As an example of where this makes a difference, if I were kidnapped and drugged to be always happy, in most forms of utilitarianism, that would be a positive outcome, even if I would prefer (prior to drugging) to be less happy and retain my freedom. Once drugged, I might not care, but my liberty to chose would be completely overlooked. In my (and I imagine most of our common-sense) ethical frameworks, that would be a bad thing.

The problem with utilitarianism is that it is often hard to figure out what action to take for the greatest utility. This is true of classical "happiness" utilitarianism, and perhaps even more true when considering the other factors when determining utility. It's hard to know what effect each action we take will have on total utility, and it's easy to fall prey to our own cognitive errors and make the wrong decision, even if, when thinking rationally, we are capable of judging what would be the best, most moral choice.

Insight from social sciences, such as psychology, economics, and their child behavioral economics, helps us figure out how to focus our actions and thoughts in order to do more good in the world, and to lead a better life. They help us understand the results of what we do, and help us learn how to think about our choices to avoid pitfalls that lead us towards worse actions.

The title is referring to the best shirt ever, which can be found here.

Is there any reason to "Teach the Controversy?"

Proponents of intelligent design (ID) are notorious for trying to use the phony scientific "controversy" about evolution as a way to open public schools to teaching religion. (There is even the notorious "wedge" document). Is there any way in which they are right?

Intelligent design is not a scientific theory, but that does not mean it is wrong. One of the arguments for the existence of a god is known as the teleological argument, which basically argues that the best explanation for things that appear intricately designed (like humans, for example) is that they are. In our everyday life, this tends to be true. If I find a cavern that looks suspiciously like it was shaped to the needs of people, it probably was. On the other hand, it could just be an accidental similarity. The argument offers no proof, just an appeal to (a somewhat incorrect) argument from personal experience.

It might surprise you to know that I do think that the crux of the "controversy" of intelligent design and evolution should be taught.

I do not mean, of course, that intelligent design should be taught as a scientific objection to evolution, but merely as part of the education in understanding what science is. Most high school student's don't really know much about what is science and what is not, and I am arguing that they should take a full course in the philosophy of science, just that further explanation, preferably with useful examples like intelligent design would be helpful. Even incorporating a basic discussion of the idea of falsifiability would be useful. How many students would later be duped into believe that intelligent design is a science if they discussed the nature of the intelligent designer and included possibilities like the Flying Spaghetti Monster or aliens?

Furthermore, to steer away from such a hot topic, the same idea of falsifiability could be first approached by discussing the concept of entropy before the concept evolution. The second law of thermodynamics (put simply) states that the entropy (simply defined as disorder) of the universe will increase. Since, in our daily lives, most disorder has a cause, for example a cat or younger sibling messing up a room, we can make a similar argument that something must be causing disorder. I think students should then be introduced to the Greek goddess Eris (the goddess of chaos and disorder, known to the Romans as Discordia). Would they think She is responsible for the Second Law of Thermodynamics? She certainly would seem a likely suspect. This is when you could introduce a concept like falsifiability.

I think the juxtaposition would be especially effective. Not only do you introduce students to a (supposedly) absurd concept that is similar to the argument for intelligent design, without even letting intelligent design get a foothold, but the ordered (designed) world that the intelligent design proponents describe is already in need of an explanation for the apparent lack of design and randomness. Not a hard challenge for IDers, but enough to make people think twice. Either way, approaching the problem of treating non-scientific theories as science from a different angle (and then showing where it's applicable in the current climate) would help students learn to think like a scientist should.