The next most likely—but still unlikely—step would be federal or state Medicare/Medicaid programs trying to regulate what kind of services they’ll pay for, in an effort to prevent these multiple births. In most cases, I don’t believe public or private money is available for fertility treatment, but I’m not expert in that area. Certainly, private insurers can decide, by contract, what they will and won’t cover, but when the government gets involved, it becomes more problematic. That could be seen as the state mandating forced embryo reductions.
The only place that this could be regulated with any type of efficiency would be in the professional responsibility codes and the licensing boards of the various health care specialties.
What role can and should health care providers play in situations such as this? Where do their responsibilities end?
Randy D. Danielsen, PhD, PA-C, DFAAPA, Dean of the Arizona School of Health Sciences at A. T. Still University and Clinician Reviews PA Editor-in-Chief: We as clinicians must first require patients to be competent in their decision making, indicating the ability to make choices based on an understanding of the relevant consequences of their action. For the most part, this is subjective and relies on the skills of the clinician in recognizing the ability of the patient to understand and give consent.
All clinicians have an obligation to be patient advocates in their area of expertise, but this does not give them the authority to overrule patients (except in certain situations).
Marie-Eileen Onieal: Given that this patient already had six young children, at least two with special needs, I think the role of the provider is to counsel the woman against trying to have more children. Providing for a large family takes energy, patience, and finances. I do not doubt that she loves the children; I just doubt that she is able to provide for their developmental needs—even the most basic physiological and safety needs. Clearer heads must prevail in situations where the person may not have sound judgment or may not have fully considered the consequences of his or her decision.
I think that those professionals whose specialty is infertility and assisting women in getting pregnant must have a moral code, a gauge if you will, that not only puts a stop to repeated failed attempts but also repeated successful births, especially if a pregnancy has resulted in multiple births. I think the responsibility is to have the ability to say “no,” and that responsibility doesn’t end.
Stephen Nunn: The role of the provider is an active and interactive one. The mother should undergo a psychologic or psychiatric evaluation. Risks and benefits need to be clearly explained and explored in an unbiased atmosphere. The provider has, in my opinion, the right to put limits on their involvement, such as adhering to established guidelines, protecting the potential fetuses’ health, insisting on a mental health evaluation, and refusing to be a party, if necessary.
Austin Potenza: Our medical system has gone, in the past 50 years, from one of paternalistic physicians and caregivers who really controlled all of the major decision-making in health care to one where it’s the patient who now is the king, makes all the major decisions, and is involved in his or her care. The health care provider is there to facilitate, maybe guide, those decisions, but not to interfere in them, unless they involve illegality (ie, assisted suicide) or overriding personal ethical beliefs (ie, abortion). But the decisions are ultimately the responsibility of the patient, if the patient is competent.
The point at which the caregiver’s responsibility becomes heightened is the point at which damage is being done to the patient—or, in cases such as this, to the fetuses, and that damage is foreseeable and preventable. Short of that, the caregiver’s role is generally secondary to the patient’s when it comes to medical decision-making.
What, if any, impact do you think the scientific/medical achievement in this case—which culminated in the successful delivery of octuplets —had on the clinicians’ judgment?
Marie-Eileen Onieal: I think that this event has placed the fertility specialty in jeopardy of being regulated for the wrong reasons. I think the physician took advantage of the science available.
Randy Danielsen: The technology in this case seems to have overridden the social implications. I am sure this case will be added to many others where the rights of the individual counter the ethical obligations of the provider in an absence of legal intervention.
Rebecca Scott: The way it comes across to me is that there’s a certain kind of arrogance in doing that kind of thing. And it’s the same kind of arrogance that we had a century ago, saying, “You’re mentally retarded; you should not be having children, therefore I am sterilizing you whether you want to be sterilized or not.” It’s kind of the flip side of that attitude.