Ethical limits on fertility drugs and multiple pregnancies

Ethical Problem or Dilemma

The ethics of fertility drugs and multiple births: Issue summary

The notoriety given to the 'octomom' Nadya Suleman has highlighted the ethical questions surrounding multiple births. Legally, there are few guidelines regarding the number of embryos that can be implanted into a potential mother's womb or the use of fertility drugs to stimulate ovary production. However, there are tremendous health risks to both the mother and children with pregnancies involving multiple births -- even twins. "During the pregnancy, the fetuses are cramped inside the uterus and compete for the same resources, and some may be weaker or smaller than others. The eight children…weighed from 3.4 pounds to 1.8 pounds...The media should not make this into heroic case," said one doctor, "This is anything but a heroic case. This is very bad medicine" ("Extreme multiple births," CNN, 2009).

Basic ethical and legal issues

Thus, it is arguable that to protect the life of the mother, to protect the lives of her future children, and also to contain the tremendous healthcare costs that children born as a result of multiple pregnancies pose to society, reproductive technology such as fertility drugs should be heavily regulated. The counterweight to this argument is that legally, women fought for decades for reproductive autonomy. Just because certain ethical decisions make someone uncomfortable, personally -- such as late-term abortion or multiple pregnancies -- does not mean that they should be outlawed, as the impingement upon the individual's privacy ultimately causes more harm to the social contract between government and its citizens. In fact, arguing that doctors should not have an 'opt out' option regarding abortion has been a core part of the pro-reproductive rights movement, as this limits women's access to abortion. Increasing rather than decreasing access and choice is a cornerstone of reproductive freedom

Formal guidelines

The usual cause of multiple pregnancies (in nature twins are rare, multiples over three almost unheard-of) is the use of fertility drugs. "The cost of treatment often persuades couples to try infertility drugs instead of opting for the more predictable IVF, Grainger says. One cycle of IVF can cost $10,000 while fertility drugs can cost a few hundred dollars (Roan, 2007, p.3). This is ironic, given that insurers could actually save money in the long run, as well as limit health risks and heart ache, by covering IVF," which implants an embryo rather than encourages the woman's body to hyper-produce eggs. But "few states with mandatory insurance for IVF still require couples to undergo three cycles of ovulation induction and artificial insemination before IVF" thus encouraging the use of a technology more likely to result in multiple births (Roan, 2007, p.4).

When contemplating the use of fertility drugs or IVF, the American College of Obstetrics and Gynecology advocates discussing the possibility of selective reduction and the patient's comfort level with this practice before any procedures are performed. However, its guidelines, are not binding. For example, "the U.S. fertility industry has guidelines on how many embryos doctors can implant, with the number varying by age and other factors. The guidelines call for no more than one or two for a generally healthy woman under 35, and no more than three to five, depending on the embryos' maturity, for women over 40" (Watkins & Neergaard 2008). Eight embryos would be "well beyond" these suggestions, and clinics that clearly violate suggested policies can removed from the Society for Assisted Reproductive Technology, which in turn affects whether insurance covers their services. "But the guidelines do not have the force of law" (Watkins & Neergard 2008)

Analysis

Given the increasing costs of healthcare, a more utilitarian calculus of the use of that technology must be introduced -- relying upon the individual ethics of doctors is not enough. To reduce the costs and risks of fertility drugs and multiple births, what are now only suggested guidelines by the American Medical Association (AMA) must become mandatory. Doctors who violate those guidelines should lose the ability to practice their profession. A cost-benefit analysis of allowing patients to exercise their choice must weigh patient autonomy with the dangers high-risk pregnancies cause to society. Infants with severe health problems, high costs, and other dangers outweigh privacy concerns. If the AMA does not act, then legislative authorities must step in.

Single or competing theories

Does this mean that in a deontological sense that to behave as if setting law 'for all time,' one must permit regulation of abortion? Not necessarily. On a situational basis, one must look at the specific consequences of reproductive technology, specifically fertility drugs, from a health policy perspective, not privacy laws in the abstract.

Public-policy implications

If doctors will not regulate their profession's use of fertility drugs, the government may need to intervene -- however, there is the uncomfortable specter of such laws being challenged by the U.S. Supreme Court in terms of the questions they pose about private reproductive decisions. Demanding more comprehensive coverage by healthcare insurance companies for IVF technology, to reduce use of fertility drugs; mandating preliminary psychiatric screening of individuals seeking treatment; and other limits could be placed upon the technology within the guidelines of past legal precedents.

Normative conclusions

Assisted reproductive technology has a high risk of generating multiple pregnancies, and a high cost for society in terms of the education and medical support of children of multiple births. Thus greater regulation of such technology, such as fertility drugs, must be mandated, ideally by the medically profession itself, or by the U.S. Congress.