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.

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?